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| chizophrenia |
Early Conceptualizations of Schizophrenia
A diagnosis of schizophrenia has traditionally been considered tantamount to a ‘prognosis of doom’ (Deegan, 1997, p.16), which denied all hope of recovery or even of a reasonably satisfying life. Mental health professionals, in particular medical professionals, have a pessimistic outlook regarding the prognosis for schizophrenia (Hugo, 2001; Jorm et al., 1999). The idea that schizophrenia had an inevitable deteriorating course culminating in a life which revolved around stabilization, medication management and survival, has its roots in early descriptions, in which chronicity was considered a criterion for schizophrenia. The earliest description of schizophrenia was that of Emil Kraepelin, who, over many years of clinical observation, asserted that the diseases then known as hebephrenia, catatonia, and paranoia were all characterized by commencement in adolescence followed by a progressively deteriorating course culminating in dementia (1913, cited in Weiner, 1966/1997; Turner, 1999). Kraepelin believed that these diseases all had a common aetiology, course and outcome, and should be identified as forms of a single disorder, dementia praecox, the fundamental criterion for which was its outcome, dementia (Turner, 1999; Pull, 2002). Kraepelin considered the illness to be an irreversible disease of the brain, probably caused by autointoxication – toxicity due to metabolic or other bodily processes (Turner, 1999) – and was not open to the idea that any symptoms of the illness could have psychological underpinnings (Weiner, 1966/1997). Although 12% of Kraepelin’s patients made a complete, or almostcomplete, recovery (Warner, 2004), he felt that those who recovered had been incorrectly diagnosed, as an outcome of dementia was fundamental to the disease (Weiner, 1966/1997; Read, Mosher and Bentall, 2004).
Eugen Bleuler, on the other hand, did not think that dementia was an essential aspect of the disease, and he noted that the illness did not always commence in adolescence (E. Bleuler, 1911/1950). He asserted that the fundamental symptom of schizophrenia was a ‘splitting’ of the various psychic functions – a loosening of associations between ideas and incongruous emotional responses. Bleuler coined the term schizophrenia, which comes from the Greek for ‘to split’ (schizin) and ‘mind’ (phren), and advocated the use of this term to replace dementia praecox (E. Bleuler, 1911/1950). Bleuler elaborated on Kraepelin’s formulation of dementia praecox with a number of new concepts. First, he argued that symptoms could range over a continuum from the almost unnoticeable to the most florid; second, he claimed that the label schizophrenia could apply to people who are making reasonable life adjustments in the community, with no psychotic symptoms; and third, he asserted that, although a person may be socially reinstated after an acute episode, residual symptoms were always present (Weiner, 1966/1997). Bleuler also argued that schizophrenia was not one single illness, but rather a group of several diseases with different aetiologies, courses and outcomes (Pull, 2002). He added two new subgroups: simple schizophrenia, which broadened the concept of schizophrenia considerably (to apparently include those who hold menial jobs and bad housewives who are nagging shrews); and latent schizophrenia, which parallels later concepts of schizoid and schizotypal personality (Wing, 1999). Bleuler’s conceptualization of schizophrenia was much more psychodynamic than was Kraepelin’s, and he believed that there was a link between symptoms of schizophrenia and psychological processes (Weiner, 1966/1997). Bleuler posited that the symptoms of schizophrenia may be the result of psychological factors, but was unsure as to the underlying cause of the disease. He concluded that schizophrenia was a group of disorders, some endogenous (and therefore organic), and some reactive (and therefore psychological) (E. Bleuler, 1911/1950; Clare, 1980). The organic form carried a worse prognosis than the reactive form.
In contrast to those of Kraepelin, 60% of Bleuler’s patients recovered well enough to work and support themselves outside hospital. There are a number of possible explanations for this difference in outcome. First, Bleuler broadened the definition of schizophrenia to include those with a better prognosis; and second, Kraepelin would have defined recovery as freedom from symptoms, rather than social functioning (Warner, 2004). However, we cannot overlook the effects of Bleuler’s more psychodynamic perspective, and his belief that there were psychogenic causes for much of the observed symptomatology (Warner, 2004). This point of view resulted in a more therapeutic approach to treatment, in which great importance was placed on minimizing hospital-based care, on the quality of the person’s environment, and on providing opportunities for work (Warner, 2004). Although Bleuler did not agree that schizophrenia necessarily resulted in dementia, neither did he believe that people ever fully recovered: ‘Personally I have never treated a patient who has proved on close examination to be entirely free from signs of the illness’ (E. Bleuler, 1911/1950, p. 256).
These early formulations of Kraepelin and Bleuler have had long-reaching effects.
With no firm evidence of its aetiology, schizophrenia has continued to be conceptualized and classified in terms of its clinical manifestations. Theorists have classified the symptoms of schizophrenia on a number of dimensions, in attempts to improve diagnosis and prognosis. In terms of diagnosing schizophrenia, the formulations of Bleuler (1911/1950) and Schneider (cited in Pull, 2002) have been widely influential.
Bleuler differentiated fundamental symptoms from accessory symptoms. The fundamental symptoms – disturbances in association and affect, ambivalence and autism – were always present in schizophrenia, while the accessory symptoms – including hallucinations and delusions – may or may not be present, and may also be present in other illnesses. The fundamental symptoms were direct manifestations of the disorder, and therefore necessary for a diagnosis of schizophrenia, whereas the accessory symptomswere psychological reactions to the illness, and were not required for a diagnosis (E. Bleuler, 1911/1950; Pull, 2002). In contrast to Bleuler, Schneider (1950, cited in Pull, 2002) held that such symptoms as hallucinations and delusions were pathognomonic of schizophrenia. That is, these symptoms alone were sufficient to give a diagnosis of schizophrenia. Schneider differentiated between abnormal experiences and abnormal expressions (1950, cited in Pull, 2002). He identified 11first-rank symptoms, which can be grouped into three categories: passivity experiences, in which thoughts, emotions and actions are felt to be externally controlled; auditory hallucinations in the third person; and primary delusions, which arise suddenly and without explanation from a normal perception (Clare, 1980). These abnormal experiences he called ‘first-rank’ symptoms, and the presence of any one of these was sufficient for a diagnosis of schizophrenia. ‘Second-rank’ symptoms included disturbances in language, writing and movement, affective symptoms and emotional blunting, all of which could occur in other illnesses (Clare, 1980).
A diagnosis of schizophrenia has traditionally been considered tantamount to a ‘prognosis of doom’ (Deegan, 1997, p.16), which denied all hope of recovery or even of a reasonably satisfying life. Mental health professionals, in particular medical professionals, have a pessimistic outlook regarding the prognosis for schizophrenia (Hugo, 2001; Jorm et al., 1999). The idea that schizophrenia had an inevitable deteriorating course culminating in a life which revolved around stabilization, medication management and survival, has its roots in early descriptions, in which chronicity was considered a criterion for schizophrenia. The earliest description of schizophrenia was that of Emil Kraepelin, who, over many years of clinical observation, asserted that the diseases then known as hebephrenia, catatonia, and paranoia were all characterized by commencement in adolescence followed by a progressively deteriorating course culminating in dementia (1913, cited in Weiner, 1966/1997; Turner, 1999). Kraepelin believed that these diseases all had a common aetiology, course and outcome, and should be identified as forms of a single disorder, dementia praecox, the fundamental criterion for which was its outcome, dementia (Turner, 1999; Pull, 2002). Kraepelin considered the illness to be an irreversible disease of the brain, probably caused by autointoxication – toxicity due to metabolic or other bodily processes (Turner, 1999) – and was not open to the idea that any symptoms of the illness could have psychological underpinnings (Weiner, 1966/1997). Although 12% of Kraepelin’s patients made a complete, or almostcomplete, recovery (Warner, 2004), he felt that those who recovered had been incorrectly diagnosed, as an outcome of dementia was fundamental to the disease (Weiner, 1966/1997; Read, Mosher and Bentall, 2004).
Eugen Bleuler, on the other hand, did not think that dementia was an essential aspect of the disease, and he noted that the illness did not always commence in adolescence (E. Bleuler, 1911/1950). He asserted that the fundamental symptom of schizophrenia was a ‘splitting’ of the various psychic functions – a loosening of associations between ideas and incongruous emotional responses. Bleuler coined the term schizophrenia, which comes from the Greek for ‘to split’ (schizin) and ‘mind’ (phren), and advocated the use of this term to replace dementia praecox (E. Bleuler, 1911/1950). Bleuler elaborated on Kraepelin’s formulation of dementia praecox with a number of new concepts. First, he argued that symptoms could range over a continuum from the almost unnoticeable to the most florid; second, he claimed that the label schizophrenia could apply to people who are making reasonable life adjustments in the community, with no psychotic symptoms; and third, he asserted that, although a person may be socially reinstated after an acute episode, residual symptoms were always present (Weiner, 1966/1997). Bleuler also argued that schizophrenia was not one single illness, but rather a group of several diseases with different aetiologies, courses and outcomes (Pull, 2002). He added two new subgroups: simple schizophrenia, which broadened the concept of schizophrenia considerably (to apparently include those who hold menial jobs and bad housewives who are nagging shrews); and latent schizophrenia, which parallels later concepts of schizoid and schizotypal personality (Wing, 1999). Bleuler’s conceptualization of schizophrenia was much more psychodynamic than was Kraepelin’s, and he believed that there was a link between symptoms of schizophrenia and psychological processes (Weiner, 1966/1997). Bleuler posited that the symptoms of schizophrenia may be the result of psychological factors, but was unsure as to the underlying cause of the disease. He concluded that schizophrenia was a group of disorders, some endogenous (and therefore organic), and some reactive (and therefore psychological) (E. Bleuler, 1911/1950; Clare, 1980). The organic form carried a worse prognosis than the reactive form.
In contrast to those of Kraepelin, 60% of Bleuler’s patients recovered well enough to work and support themselves outside hospital. There are a number of possible explanations for this difference in outcome. First, Bleuler broadened the definition of schizophrenia to include those with a better prognosis; and second, Kraepelin would have defined recovery as freedom from symptoms, rather than social functioning (Warner, 2004). However, we cannot overlook the effects of Bleuler’s more psychodynamic perspective, and his belief that there were psychogenic causes for much of the observed symptomatology (Warner, 2004). This point of view resulted in a more therapeutic approach to treatment, in which great importance was placed on minimizing hospital-based care, on the quality of the person’s environment, and on providing opportunities for work (Warner, 2004). Although Bleuler did not agree that schizophrenia necessarily resulted in dementia, neither did he believe that people ever fully recovered: ‘Personally I have never treated a patient who has proved on close examination to be entirely free from signs of the illness’ (E. Bleuler, 1911/1950, p. 256).
These early formulations of Kraepelin and Bleuler have had long-reaching effects.
With no firm evidence of its aetiology, schizophrenia has continued to be conceptualized and classified in terms of its clinical manifestations. Theorists have classified the symptoms of schizophrenia on a number of dimensions, in attempts to improve diagnosis and prognosis. In terms of diagnosing schizophrenia, the formulations of Bleuler (1911/1950) and Schneider (cited in Pull, 2002) have been widely influential.
Bleuler differentiated fundamental symptoms from accessory symptoms. The fundamental symptoms – disturbances in association and affect, ambivalence and autism – were always present in schizophrenia, while the accessory symptoms – including hallucinations and delusions – may or may not be present, and may also be present in other illnesses. The fundamental symptoms were direct manifestations of the disorder, and therefore necessary for a diagnosis of schizophrenia, whereas the accessory symptomswere psychological reactions to the illness, and were not required for a diagnosis (E. Bleuler, 1911/1950; Pull, 2002). In contrast to Bleuler, Schneider (1950, cited in Pull, 2002) held that such symptoms as hallucinations and delusions were pathognomonic of schizophrenia. That is, these symptoms alone were sufficient to give a diagnosis of schizophrenia. Schneider differentiated between abnormal experiences and abnormal expressions (1950, cited in Pull, 2002). He identified 11first-rank symptoms, which can be grouped into three categories: passivity experiences, in which thoughts, emotions and actions are felt to be externally controlled; auditory hallucinations in the third person; and primary delusions, which arise suddenly and without explanation from a normal perception (Clare, 1980). These abnormal experiences he called ‘first-rank’ symptoms, and the presence of any one of these was sufficient for a diagnosis of schizophrenia. ‘Second-rank’ symptoms included disturbances in language, writing and movement, affective symptoms and emotional blunting, all of which could occur in other illnesses (Clare, 1980).
A diagnosis of schizophrenia could also be given when only second-rank symptoms were present (Schneider, 1950, cited in Pull, 2002).
Whereas Kraepelin’s definition of schizophrenia was based on onset, course and prognosis, Bleuler focused on the dissociative symptoms and Schneider emphasized the importance of the psychotic symptoms such as hallucinations and delusions. All three formulations have been influential to varying degrees in different diagnostic systems until the present day, including the Diagnostic and Statistical Manual of Mental Disorders (4th Edition) (DSM-IV; American Psychiatric Association, 1994), the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1992) and Present State Examination (PSE; Wing, Cooper and Sartorius, 1974).
Whereas Kraepelin’s definition of schizophrenia was based on onset, course and prognosis, Bleuler focused on the dissociative symptoms and Schneider emphasized the importance of the psychotic symptoms such as hallucinations and delusions. All three formulations have been influential to varying degrees in different diagnostic systems until the present day, including the Diagnostic and Statistical Manual of Mental Disorders (4th Edition) (DSM-IV; American Psychiatric Association, 1994), the tenth revision of the International Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1992) and Present State Examination (PSE; Wing, Cooper and Sartorius, 1974).
