Emile Kraepelin was a German psychiatrist practising in the late nineteenth century. In Kraepelin’s time the psychiatric classification system was still very much in flux and there was a shifting consensus about matching particular symptoms with specific mental diseases. This situation provided scope for individual psychiatrists to ‘discover’ new disease entities and then persuade their colleagues to recognise their new discovery. Kraepelin was the first psychiatrist to observe a certain pattern of madness that had an early onset and, as he falsely thought, led finally to a deteriorating condition. He called the new disease dementia praecox—dementia of early life.
Kraepelin’s argument was that three psychiatric conditions, previously recognised separately, were actually different aspects of a single disease. The three pre-existing disease entities were hebephrenia, which was characterised by ‘aimless, disorganised and incongruous behaviour; catatonia, in which the individual might be negativistic, motionless or even stuporous or, at other times, extremely agitated and incoherent; and finally dementia paranoides, in which delusions of persecution and grandeur were prominent.’[18]
Kraepelin had to overcome professional opposition to gain recognition for his new interpretation. One of its central features was a clear distinction from other forms of madness, which sometimes produced similar symptoms, but which have a demonstrable biological cause, such as cerebral syphilis. He also sought to distinguish dementia praecox from other forms of mental illness that are clearly stress induced, and also from cyclical mood disorders. The description he gave of dementia praecox has become the foundation for the modern psychiatric description of schizophrenia.
Kraepelin worked as part of a highly successful team of psychiatric researchers that included Alzheimer, after whom Alzheimer’s Disease takes its name. Kraepelin believed that dementia praecox was a ‘brain disease and that its neuropathological substrates would be identified by the new techniques that he and his investigative team were developing.’[19] This focus on a search for a biological cause was largely based on what emerged to be a false assumption that the disease necessarily takes a deteriorating course, from which sufferers do not recover.
As Kraepelin’s research progressed, however, he began to find that the symptoms of a substantial percentage of the patients he had selected, according to the new diagnostic criteria, did not in fact follow a deteriorating course, and that 12 per cent of these patients actually made a complete recovery. This potential for recovery intrigued a Swiss psychiatrist named Eugen Bleuler, who realised that the new disease of dementia praecox had been misnamed: ‘Stimulated by the psychoanalytical theories of his assistant, Carl Jung, Dr Bleuler formulated a new unifying concept for the condition and gave it a new name.’[20] Bleuler believed that the major identifying characteristic of the condition was not a progressive deterioration but was instead a discontinuity and fragmentation between thinking and feeling. So he reformulated the description and called the condition schizophrenia, meaning split mind.
In 1911 Bleuler published a monograph entitled Dementia Praecox or the Group of Schizophrenias in order to propagate his new description. Although this book was not translated into English for some thirty years it is generally recognised as the foundation for the modern psychiatric understanding of schizophrenia.
In the first few pages of the book Bleuler painstakingly explained why Kraepelin’s description was unsatisfactory and why he found it necessary to rename the condition. His argument was that the name dementia praecox inappropriately limited the disease to young people who progressively deteriorate. He said this had caused great confusion within the psychiatric profession in a number of countries, since it was readily apparent that many victims experienced the first onset later in life, and not all victims progressively deteriorated.
Bleuler then went on to categorise the symptomatology of schizophrenia into two groups. The first group he called ‘fundamental symptoms’. These were symptoms ‘that are present in every case and at every period of the illness even though, as with every other disease symptom, they must have attained a certain degree of intensity before they can be recognised with any certainty’. According to Bleuler the ‘fundamental symptoms consist of disturbances of association and affectivity, the predilection for fantasy as against reality, and the inclination to divorce oneself from reality (autism).[21]
The second group of symptoms he called ‘accessory symptoms’. These involve ‘manifestations such as delusions, hallucinations or catatonic symptoms. These may be completely lacking during certain periods, or even throughout the entire course of the disease; at other times they alone may permanently determine the clinical picture.’[22]
As a ‘disturbance of association’, thought disorder was one of Bleuler’s ‘fundamental symptoms’, which he described in an unusually candid fashion. He supplied numerous examples taken from conversations with his patients, as well as extracts from their letters, to demonstrate what he thought were the illogical and bizarre effects that can be produced by inappropriately associating ideas. The effect was to give an insight into psychiatric thinking that is rarely available in modern psychiatric writing.
One of Bleuler’s examples, for instance, utilised quotations from a patient’s written impression of ancient Egypt. According to Bleuler the patient’s writing demonstrated a failure to control impulses of fantasy which had opened the way for all sorts of incongruous material to be introduced. The writing referred to the habits and preferences of various national and religious groupings including Parsees, Afghans, Jews, Moors and Arabs and finished with the assertion that ‘China is the Eldorado of the Pawnees’.[23] Much of this material clearly does not belong in a factual account of ancient Egypt. But Bleuler’s argument that the writing demonstrates clinical evidence of madness is also doubtful in a modern context. What might have been an excellent example of bizarre self-expression to a turn-of-century scientist is, to a contemporary reader, somewhat familiar as a variety of stream-of-consciousness writing.
Bleuler also gaves examples of questions that he asked his schizophrenic patients. The answers they gave are then offered as clinical evidence to demonstrate the nature of disordered thinking. But as Bleuler described his method he seems to be unaware that the patients might have given flippant or witty answers, or teased or joked with him, instead of expressing their most seriously held beliefs. What might be objectivity in other scientific research looks more like naivety—and a tendency towards the literal—in psychiatric research.
He gave an example of schizophrenic symptoms: ‘A female patient, supposed to help in the household work, is asked why she is not working. The answer, "But I don’t understand any French", is logically related neither to the question nor the situation.’[24] Bleuler’s assumption is that her answer indicated disordered thoughts. However, it is possible to read a sophisticated retort into the answer. If, for instance, a similar dialogue were encountered in a novel a reader might simply assume that the woman was protesting against being asked to do housework and, perhaps, with tongue in cheek, was asserting that she was not a French maid.
Throughout Bleuler’s book there is an unsettling single-mindedness and inflexibility in the record of his interactions with patients. He gives the impression of functioning only as an investigative scientist in his personal interactions with patients, so that everything they say is scientific evidence before it is human communication. Patients might have encountered some difficulty in responding to this scientist who was talking to them as if they were all laboratory exhibits.
This same point has been raised by R. D. Laing in relation to Kraepelin’s work. In Lectures on Clinical Psychiatry Kraepelin described a clinical examination of a female patient he had conducted in front of a live audience of doctors to demonstrate dementia praecox. He described how the woman paced back and forth on a stage while he attempted to distract her. According to Kraepelin the woman’s indifference to his activities constituted the evidence of her condition. Laing made his point about Kraepelin by isolating all his actions in relation to the woman and printing them in italics.
"… On attempting to stop her movement … if I place myself in front of her with my arms outstretched … If one takes firm hold of her … will not allow it to be forced from her … If you prick her on the forehead with a needle …" .[25]
Laing’s purpose was to separate out the psychiatrist’s own actions in his account and to demonstrate how extraordinary these actions were and how bizarre was the situation with which the woman had to deal.
Both Kraepelin’s and Bleuler’s works raise an important question about psychiatric research work in general. Is it possible for a patient’s mind to be used as a laboratory exhibit for scientific investigation, and for it still to give responses that are considered normal? Perhaps another way of examining this problem is to ask: if a psychiatrist assumes a patient’s mind is diseased, and the patient perceives the psychiatrist’s assumption, how should the patient behave?
This second question implies that patients might have choices about how to adapt to the situations they find themselves in. The possibility that schizophrenic symptoms are merely adaptive behaviour will be discussed more fully in Chapter 7. However, it seems apparent that the argument for a pathological cause relies heavily on the assumption that the indicators of schizophrenia are necessarily involuntary behaviours. The medical model tends to disregard the possibility that schizophrenic symptoms might sometimes be a deliberate strategy induced by the circumstances in which psychiatry is practised.
Next: Regression Theories
[18] Richard Warner, Recovery From Schizophrenia, p. 10.
[19] Nancy C. Andreasen et al., ‘Regional brain abnormalities in schizophrenia measured with magnetic resonance imaging’, pp. 1763–70.
[20] Warner, op. cit., p. 14.
[21] Eugen Bleuler, Dementia Praecox or the Group of Schizophrenias, pp. 13, 14.
[22] Ibid., p. 13.
[23] Ibid., p. 15.
[24] Ibid., p. 22.
[25] R. D. Laing, The Politics of Experience.