The Evolution of Schizophrenia
Bleuler was born in 1857 in the village of Zollikon, approximately one hour’s walk from the centre of Zurich, and now a suburb of the city.2 According to an account of his life written by his son Manfred (also a psychiatrist), his decision to become a doctor was partly inspired by observing local dissatisfaction with the German-speaking medical professors who had been appointed to positions at the nearby Burghölzli Mental Hospital, which had opened its doors for the first time in 1870.
After graduating in medicine at the University of Zurich in 1881, Bleuler studied in Paris, London and Munich, before joining the staff at the Burghölzli. There, he worked under the director, August Forel, a biological psychiatrist who had developed an appreciation for the more psychological aspects of psychiatric care after discovering that laymen were sometimes better able to cure alcoholics than physicians. (Consulting one successful lay therapist, Forel was told, ‘No wonder, Herr Professor, I am an abstainer while you are not.’)3
In 1886, at the age of 29, Bleuler became director of a psychiatric clinic at Rheinau, a small farming village. The clinic was located in an eighth-century monastery on an island in the Rhine, which had been turned into a hospital in 1867 and which, at the time of Bleuler’s arrival, was reputed to be one of the most backward psychiatric institutions in Switzerland. He set about reforming the hospital and improving the quality of life of its patients. In Manfred’s account:
Bleuler was not yet married, and lived there alone, in contact with his patients. He worked with them (mostly in agriculture), organized their free time (for instance, hiked with them, played in the theatre with them, and danced with them). He was also the general physician of the patients of the Clinic and the inhabitants of the village. During his life with the patients, Bleuler had always a memo-pad at hand, where he noted what touched and interested him in his patients’ behaviour. He frequently noted in shorthand what the patients actually said.4
When a typhoid epidemic broke out, Bleuler was able to recruit some of his patients as nurses. They performed well, prompting him to observe that mental illness, far from dominating the life of patients, could retreat into the background when a crisis loomed. Because he had formed such close relationships with the inhabitants of the hospital, it was with regret that he returned to the Burghölzli, where, in 1898, he was appointed Forel’s successor. Two years later, he appointed Carl Gustav Jung to a junior post in the hospital. Jung, who was to become Sigmund Freud’s most famous disciple, and later the first rebel of the psychoanalytic movement, was to have an important impact on Bleuler’s thinking about the causes of mental illness. However, it seems that the two men never really liked each other, although the fact that most observers commented on Bleuler’s warmth and openness suggests that the fault was Jung’s. Certainly, Jung adapted with difficulty to the workaholic regime established by Bleuler at the hospital, which required doctors to make their rounds before breakfast.
At the time, Freud’s theory of psychoanalysis was just beginning to attract the attention of psychiatrists and psychologists outside his home city of Vienna. According to the theory, mental illness was caused by unconscious mental forces or repressed ideas, which intruded into consciousness in a distorted form, and thereby generated the patient’s symptoms. This discovery seemed to promise a new kind of psychological treatment for the mentally ill. During the period that he worked in the Burghölzli between 1900 and 1910, Jung therefore formed a small discussion group dedicated to examining the claims of psychoanalysis. He also undertook a series of studies of dementia praecox that, although initially developed with his colleagues in Zurich, drew him progressively closer to Freud’s ideas. Most important of these were studies in which word associations were used to probe the unconscious ‘feeling-toned-complexes’ which Jung believed lay at the root of the patient’s dreamlike thoughts and speech.5
Encouraged by the successful work of his junior colleague, Bleuler participated in the discussion group and became convinced that psychoanalysis represented an important breakthrough in the theory and practice of psychiatry. This enthusiasm became very important to Freud, as Bleuler was the first respected academic psychiatrist to take the new theory seriously. Unfortunately for Freud, Bleuler’s enthusiasm did not blunt his critical faculties. By the time of the first international meeting of psychoanalysts, organized by Jung and held in the Hotel Bristol in Salzburg in April 1908, tensions had begun to develop between the two great men. These tensions, which eventually led to Bleuler’s resignation from the newly formed International Psychoanalytic Association, reveal much of Bleuler’s character and his approach to his work.
According to a letter written by Bleuler to Freud in October 1910:
There is a difference between us, which I decided I shall point out to you, although I am afraid it will make it emotionally more difficult for you to come to an agreement. For you evidently it became the aim and interest of your whole life to establish firmly your theory and to secure its acceptance. I certainly do not underestimate your work. One compares it with that of Darwin, Copernicus and Semmelweis. I believe too that for psychology your discoveries are equally as fundamental as the theories of those men for other branches of science, no matter whether or not one evaluates advancements in psychology as highly as those in other sciences. The latter is a matter of subjective opinion. For me, the theory is only one new truth among other truths. I stand up for it because I consider it valid and because I feel I am able to judge it since I am working in a related field. But for me this is not a major issue, whether the validity of these views will be recognized a few years sooner or later. I am therefore less tempted than you to sacrifice my whole personality for the advancement of the cause.6
In March 1911 Bleuler wrote to Freud in defence of a psychiatrist who had been asked to resign from the Association because of a difference of opinion:
‘Who is not with us is against us,’ the principle ‘all or nothing’ is necessary for religious sects and for political parties. I can understand such a policy, but for science I consider it harmful. There is no ultimate truth. From a complex of notions one person will accept one detail, another person another detail. The partial notions, A and B, do not necessarily determine each other. I do not see that in science if someone accepts A, he must necessarily swear also for B. I recognise in science neither open nor closed doors, but no doors, no barriers at all.7
This kind of eclecticism is clearly evident in Bleuler’s most famous work, Dementia Praecox or the Group of Schizophrenias, which drew heavily on his observations of patients at Rheinau, and which was rich in clinical detail. It began with acknowledgements to Kraepelin (for grouping together and describing the separate symptoms of dementia praecox) and to Freud (for enlarging the concepts available to psychopathologists). However, just as Bleuler found it difficult to swallow the entire body of Freudian theory without reservation, so too he found it difficult to agree completely with Kraepelin’s characterization of the most severe type of mental illness.
The first and most obvious difference between Kraepelin and Bleuler concerned the name that should be given to the illness. Bleuler believed that the term ‘dementia praecox’ was misleading for two reasons. First, the illness did not always result in an extreme form of mental deterioration (it was not a dementia). Second, although it usually began in late adolescence, the illness sometimes first appeared in later life (it was not always praecox). To the confusion of lay people ever since, Bleuler proposed the new term schizophrenia to describe the disorder. In doing so, he did not mean to imply that the illness caused a split personality of the kind sometimes portrayed in paperback novels and Hollywood films.* Rather, Bleuler was suggesting that, at the core of the illness, there was a separation between the different psychic functions of personality, thinking, memory and perception.
Bleuler, like Kraepelin, believed that schizophrenia was the product of some kind of biological disorder, and toyed with the idea that it was caused by an accumu
lation of abnormal metabolites in the blood. However, unlike the early Kraepelin, he was also interested in the psychology of his patients’ symptoms, and was impressed by the extent to which they could vary from one individual to another. In order to make sense of this variation, he made use of ideas borrowed from Freud and psychoanalysis, and combined them with his own notions about the mental mechanisms responsible for normal thinking and reasoning. This approach led him to suppose that, underneath the most obvious but varied symptoms of schizophrenia, there was a less obvious inner unity. In an attempt to characterize this unity, he identified four subtle symptoms which he believed to be fundamental to the illness, and which have since been known to English-speaking psychiatrists as Bleuler’s four ‘As’.
First, and most importantly, there was a loosening of the associations that linked together the stream of thought, so that the patient could no longer reason coherently. In extreme cases, this could cause the sufferer to speak in a jumbled word salad, as exemplified by a modern patient’s attempt to answer the question ‘Why do you think people believe in God?’
Uh, let’s, I don’t know why, let’s see, balloon travel. He holds it up for you, the balloon. He don’t let you fall out, your little legs sticking out down through the clouds. He’s down to the smoke stack, looking through the smoke trying to get the balloon gassed up you know. Way they’re flyin’ on top that way, legs sticking out, I don’t know, looking down on the ground, heck, that’d make you so dizzy you just stay and sleep you know, hold down and sleep there. The balloon’s His home you know up there. I used to be sleep out doors, you know, sleep out doors instead of going home.8
(Since Bleuler, this kind of speech has commonly been described as thought disorder. However, in a later chapter we will see that this term is quite misleading.)
The second of Bleuler’s four ‘As’ was ambivalence – the holding of conflicting emotions and attitudes towards others. Third, schizophrenia patients were said to suffer from autism, a withdrawal from the social world resulting from a preference for living in an inner world of fantasy. Finally, there was inappropriate affect, the display of emotions that are incongruent with the patient’s circumstances.
Bleuler held that, in contrast to these fundamental symptoms, the most obvious features of schizophrenia described by Kraepelin, namely hallucinations and delusions, were mere accessory symptoms – psychological reactions to the illness rather than direct products of the disorder. Indeed, he argued that a substantial subgroup of patients, who were said to suffer from simple schizophrenia, did not experience these symptoms at all. Such people might include individuals who ‘vegetate as day labourers, peddlers, even as servants’, or ‘the wife… who is unbearable, constantly scolding, nagging, always making demands but never recognising duties’.9
Enlarging the category of schizophrenia even further, Bleuler argued that:
There is also a latent schizophrenia and I am convinced that it is the most frequent form, although admittedly these people hardly ever come for treatment. It is not necessary to give a detailed description of the various manifestations of latent schizophrenia… Irritable, odd, moody, withdrawn or exaggeratedly punctual people arouse, among other things, the suspicion of being schizophrenic.10
In his less well known Textbook of Psychiatry, the fourth edition of which was published in 1924, Bleuler extended this analysis to reconsider the relationship between schizophrenia and manic depression. Unlike Kraepelin, he came to the view that these were not separate disease entities after all, but that there was a continuum running between them, without a clear line of demarcation.11 On this view, patients could be regarded as predominantly schizophrenic or predominantly manic depressive according to the extent to which they experienced or did not experience schizophrenia symptoms (the affective symptoms normally attributed to manic depression being regarded as non-specific).
Bleuler’s contribution, then, was not only to provide an account of the psychology of dementia praecox, but also to widen the concept substantially. Indeed, on his account there seemed to be no precise dividing line between normality and illness, or between one type of madness and another. This analysis was entirely consistent with Bleuler’s clinical attitude which, as we have seen, was markedly different from Kraepelin’s. Whereas for Kraepelin the mad were subjects of scientific interest and scrutiny, for Bleuler they were fellow human beings engaged in the same existential struggles as the rest of humanity, struggles that were made more difficult by their illness.
Defining the boundaries of madness: the philosophical approach of Karl Jaspers
Broad conceptions of schizophrenia, such as Bleuler’s, highlighted the difficulty of determining exactly who suffered from the illness and who did not. This important problem was addressed, in different ways, by a group of psychiatrists whowere Kraepelin’s successors at Heidelberg, whose ideas brought about further shifts in the way that researchers thought about the illness. Foremost among them was Karl Jaspers, who became better known as a philosopher than as a psychiatrist, and who worked as a doctor for only seven years, between 1908 and 1915.12
Jaspers was born in 1883 in Oldenburg, close to the North Sea. His father was a jurist and his mother came from a local farming family. According to Jaspers’ own account, his father actively encouraged him to question authority at an early age which, unfortunately, led him into conflict with his teachers and isolated him from potential friends. Seeking solace by exploring the nearby coast and countryside, Jaspers’ mind turned to matters philosophical. He read Spinoza at the age of 17 but decided to study law rather than philosophy at university. Almost immediately it became evident to him that this decision had been a great mistake: ‘The abstractions which were used to refer to social life – a life still entirely unknown to me – proved so disappointing that I occupied myself instead with poetry, art, graphology and the theatre, always turning to something else.’13
In 1902, Jaspers decided to abandon his legal studies and study medicine. In order to explain this decision to his parents, he wrote them a memorandum:
My plan is the following: I shall take my medical state examination after the prescribed number of semesters. If then I still believe – as I do now – to possess the necessary talent for it, I shall transfer to psychiatry or psychology. After that I shall first of all start practicing as a physician in a mental hospital. Eventually I might enter upon an academic career as a psychologist, as for example Kraepelin in Heidelberg – something which I would not, however, care to express because of the uncertainty and of its being dependent upon my capabilities… Therefore, I had best state it this way: I am going to study medicine in order to become a physician in a health resort or a specialist, for example, a doctor for the mentally ill. To myself I add: the rest will come if and when.
The memorandum proved to be remarkably prescient. Despite health problems that were to affect him throughout his later life, he received his MD in 1909. By this time he had already started voluntary work at the psychiatric hospital in Heidelberg, seven years after Kraepelin had left for Munich. Kraepelin’s successor at the hospital was Franz Nissl, whose main research interest was neuropathology, but who encouraged his junior staff to develop projects across the spectrum of disciplines relevant to psychiatry. Jaspers experimented with intelligence tests, and with a new apparatus for measuring blood pressure. Describing the intellectual environment in which he began to assemble his ideas about the very nature of madness, Jaspers later recorded that:
The common conceptual framework of the hospital was Kraepelin’s psychiatry together with deviations from it, resulting in points of view and ideas for which no one person could claim individual authorship. Thus, for example, the polarity of the two broad spheres of dementia praecox (later called schizophrenia) and of the manic-depressive illnesses was considered valid.
However, Jaspers doubted whether this broad acceptance of Kraepelin’s doctrine provided a secure basis for progress in the understanding of madness. On the contrary:
The realization that scientific investigation and therapy were in a state of stagnation was widespread in German psychiatric clinics at that time. The large institutions for the mentally ill were built constantly more hygienic and more magnificent. The lives of the unfortunate inmates, which could not be changed essentially, were controlled. The best that was possible consisted of shaping their lives as naturally as possible as, for example, by successful work therapy as long as such therapy remained a humane and reasonable link in the entire organization of the patient’s life. In view of the exceedingly small amount of knowledge and technical know-how, intelligent, yet unproductive psychiatrists, such as Hoche, took recourse to a sceptical attitude and to elegant sounding phrases of gentlemanly superiority.
Jaspers therefore set himself the task of rethinking the way in which he and his colleagues studied mental illness. The originality of his approach first became evident to his colleagues in 1910, when he published a paper in which he considered whether paranoia should be regarded as an abnormal form of personality development or as an illness.14 Jaspers’ distinction between these two possibilities was novel in itself. If paranoia was a form of personality development it should reflect the understandable evolution of the patient’s inner life. If, on the other hand, paranoia was an illness it must inevitably be considered a product of the biological changes that were presumed to accompany the onset of psychosis. Even more original, however, was Jaspers’ method of addressing this distinction. In his paper he described several cases of paranoia in unusual detail, paying attention to his patients’ accounts of their lives before they entered hospital, and also their subjective experience of their symptoms. ‘With this mode of presentation, Jaspers introduced the biographical method into psychiatry: a summons to regard a patient’s illness always as part of his life history.’15
Madness Explained Page 4
