Damian Sendler: Schizophrenia’s public image is defined by madness, a split personality, unpredictable and hazardous behavior, and the assumption that schizophrenia is a chronic brain disorder. It contributes to the delay in seeking care, promotes social exclusion and prejudice, and exacerbates feelings of shame about one’s own mental health. Here, the author examines how concepts like “schizophrenia” and the “schizophrenic split personality” (Eugen Bleuler, 1857–1939) came to be, as well as how the “first rank symptoms” (all hallucinations and delusions) came to be associated with “craziness” (Kurt Schneider, 1887–1967). Dementia as a progressive brain disease was defined as a result of Emil Kraepelin’s scientific search for homogeneous groups of patients with a common underlying cause, symptom pattern, and prognosis; Eugen Bleuler’s life and professional circumstances fostered a “empathic” approach to his patients, which prompted him to place in the foreground the incoherence of cognitive and affective functioning, rather than the disease’s course; finally, Kur All three of these diagnostic approaches are combined in a strange conglomerate in modern operational diagnostic criteria, which claims to be Neo-Kraepelinean in terms of defining a categorical disease entity with a suggestion of chronicity, keeps Bleuler’s ambiguous term schizophrenia, and relies heavily on Kurt Schneider’s hallucinations and delusions. The concept of schizophrenia is still arbitrary and has no factual basis, yet it is nonetheless stigmatizing to those who are diagnosed with it.
Damian Jacob Sendler: It was an odd choice of words. It was in 1886, when the young German psychiatrist was just 30 years old, that he was appointed to the chair of psychiatry at the University of Dorpat (then in Russia; today Tartu in Estonia), where most of the population spoke languages he didn’t understand and couldn’t learn quickly, including Estonian. At one point in his memoirs, he says something like this: “The bulk of the average patients spoke and comprehended only Estonian. Most of them couldn’t interact with me without constant translation, and I couldn’t discern even the tiniest differences in pronunciation, idiomatic expressions, or the structure of words and phrases.”
Dr. Sendler: From 1886 until 1891, Kraepelin was a resident in Dorpat, where he worked. In his memoirs, Kraepelin said that he started to pay attention to the history and development of the sickness in Dorpat, and that this led him to the conclusion that “Dementia praecox” was the result of a degenerative process that he subsequently dubbed “Dementia praecox.” 21 At the University of Heidelberg in 1891, Kraepelin began his “Research Programme,” which aimed to provide stable descriptions and classifications of psychoses, that is, the identification of homogenous groups of patients with the same cause, pathophysiology, duration and result as each other. 22 To achieve this goal, he used an extensive “index card” documentation system that contained “condensed information on each patient” that he organized under different aspects, calling the results of this approach later “the victory of scientific observation over philosophical and moral contemplation.” 23 He published the 4th edition of his textbook two years after arriving in Heidelberg,24 where he introduced the concept of “Dementia praecox” as an irreversible, deteriorating, and incurable disease that started early in life and subsumed it under the heading of “Degenerating psychological processes.”.
Damian Sendler
For Kraepelin, “Dementia Praecox” and “Manic-Depressive Insanity” (Manisch-Depressives Irresein) were two distinct conditions, based on the fact that “Manic-Depressive Insanity” had an episodic and remission-based course, while “Dementia Praecox” had a more gradual progression, he wrote in the 6th edition of his textbook published in 1899.25 He created a “firewall” between the two by drawing a line on the sand. According to Kraepelin, the majority of mentally handicapped and semi-handicapped people after dementia praecox “gradually accumulate in the big mental asylums (Heil- und Pflegeanstalten); indeed, these patients, because they do not die quickly and often spend their entire lives in the asylum, constitute the bulk of the insane requiring care.”. 26 Kraepelin eventually acknowledged that dementia praecox may have full remissions, but he refused to change his diagnosis because of this. 15
Later, Kurt Schneider, who had a major impact on the definition of schizophrenia, claimed that Kraepelin’s view of the human being was similar to that of the positivist natural sciences of the 19th century, in which the psychotic person was only seen from the outside looking in.
27 According to a subsequent researcher of Kreapelin’s work, Kraepelin lacked empathy for his patients (while caring for their physical well-being in a compassionate manner). 28
Damian Jacob Markiewicz Sendler: The “chronicity” component is the one for which Kraepelin is most well-known in the context of this work. There is still a perception that schizophrenia has a worse prognosis than depression in the minds of the general public. 29 After the initial publication of Kraepelin’s foundational work, Eugen Bleuler30 and 31 noted that Kraepelin only defined one “end” of schizophrenia’s spectrum: people whose disease didn’t improve and even exhibited a progressive path. As of today, the “chronic group” may account for little more than one-third of all first episode patients, and full recovery is not uncommon. 2, 3, 4, 5, 6, 7 Although the contexts have changed dramatically, it is difficult to come to a definite conclusion because most patients now live outside institutions (hospitalism and “institutionalism” may have played a big role 100 years ago36), the empirical outcome criteria studied are wide-ranging (covering not only symptoms but also functioning and disabilities), and new treatments have been developed.
Kraepelin’s idea of Dementia praecox was rapidly attacked, first for its chronicity requirement, which was thought to be overstated, and, secondly, for abandoning psychopathological theory and offering simply a “unstructured mosaic of symptoms”.
37 Eugen Bleuler, a Swiss psychiatrist only a year younger than Kraepelin, took over the mantle of director of the “Burghölzli,” the city of Zürich’s mental university hospital, in 1898, and remained there until his retirement in 1927, focusing on the issues ignored by Kraepelin.
In 1908, Bleuler coined the term schizophrenia.
30 The extensive book “Dementia praecox oder Gruppe der Schizophrenien” (“Dementia praecox or the group of schizophrenias”)31 was published in 1911. The title was thought out to the nth degree. With the word “or,” it refers to both Bleuler’s and Kraepelin’s alternative ideas as “Dementia praecox.” “Group” and the plural “suggest” that there are several forms of the disorder (especially in regard to age of onset and course), and “schizophrenias” signals Bleuler’s focus on psychopathology, actually “rejecting” Kraepelin’s concept of “dementia precox” and making a complete conceptual U-turn.
Damien Sendler: As compared to Kraepelin, Eugen Bleuler had a very different outlook on life. He saw himself more as a doctor who cares about his patients than as a scientist trying to come up with a technique for diagnosing mental illnesses. As Eugen Bleuler’s successor at the Burghölzli, Daniel Hell38 provides an account of Bleuler’s private and professional life, which sheds light on his specific mindset, he says, “Someone who becomes a doctor… will be able to help the individual patient better than a doctor who is not able to talk with a patient and is more interested in science than in the individual patient.”
Damian Jacob Sendler
The fact that Eugen Bleuler married relatively late (in 1899, at the age of 43, shortly after he had become director of the “Burghölzli” a year earlier) and thus had much time in his early professional years to spend with his patients at the Swiss Hospital Rheinau (where he was director for 12 years from 1986 to 1898) is interestingly stressed. “He lived with his patients, 14 to 16 hours a day and work on Sundays were not rare.” When Bleuler moved in with his family in the director’s apartment, he brought along a mentally ill older sister who had previously resided with him in the family home (in fact, only a few miles away from the Burghölzli facility). When it came to communicating with his patients, Kraepelin was able to do so in the local Swiss language, which is a very peculiar German dialect that is difficult for foreigners to understand (his predecessors in the Burghölzli had similar difficulties with understanding their patients as Kraepelin had in Dorpat). Then there’s his years spent studying psychoanalysis, with Carl Gustav Jung as a mentor and Sigmund Freud as a pen pal.
When you consider all of these factors, it’s easy to see why Bleuler was recognized as an empath and why he paid attention to the finer points of his patients’ psychological functioning. His key pathogenic trait for schizophrenia was the incoherence of cognitive and emotional activities, indicated among others by loosening associations, and the name “schizophrenia” was a shorthand for these subtle psychopathological abnormalities that he characterized. The word “dysphrenia”39 had previously been coined by a few other psychiatrists as a replacement for dementia praecox, as had the phrase “intrapsychic ataxia”40. According to Bleuler, no option is better than his own: the wholly new word schizophrenia, since there is no risk of misinterpretation with that word. Although this was not the case in the long run;
Additionally, Bleuler classified hallucinations and delusions as “accessory symptoms,” which he believed were irrelevant to the diagnosis because they could be present or absent. These “accessory symptoms” were just as important as Bleuler’s focus on incoherent association and affect, which he called “basic symptoms.”.
Bleuler’s primary symptoms, apart from the term “schizophrenia,” have not been adopted permanently in psychiatric categorization systems. The descriptions of symptoms are frequently confused with interpretations, resulting in a lack of clarity, making it impossible to objectively analyze them. 41 Even in the operational DSMIII (1980) and ICD10 (1992), hallucinations and delusions were given top rank for diagnosing schizophrenia, in full opposition to Bleuler’s view that they were just “accessory.”
The name schizophrenia is all that has left from Bleuler in terms of diagnostic methods and popular stereotypes. Disintegration and incoherence of psychological processes are what Bleuler meant when he used “phren” (the Greek term for the mind), and “schizein” (to fall apart, not only divide) to convey this. It wasn’t until a few decades later that the words “conflicting nature” and “contradictoriness” began to be used by the media to describe a “split personality”. 42 As a result, the public perception of patients as unpredictable and hazardous has a significant impact. 43 It seems, however, that this preconception is confined to the more educated members of society. 44 The second conclusion is significant because it shows that people with higher levels of education are more likely to draft and implement rules and policies that discriminate against people with mental illnesses. It’s easy to see how misunderstanding the word “schizophrenia” may be harmful to patients and their families when doctors, who hold such high positions of trust, participate in a study in Austria.12
Even today, psychiatrists face communication challenges when explaining schizophrenia to patients and loved ones, and in some countries, such as Japan, the term has been officially dropped in favor of “Togo Shitcho Sho” (“integration disorder,” which is what Eugen Bleuler intended to convey when he coined the term “schizophrenia”). Japanese psychiatrists boosted the percentage of patients who were informed about their diagnosis from 37 percent to 70 percent within three years of the shift in practice. In terms of the disorder’s renaming, there is a wide range of opinion.
Several decades passed before the next U-turn occurred. In 1911, Eugen Bleuler reduced delusions and hallucinations to “accessory symptoms,” but in 1939, German psychiatrist Kurt Schneider raised them to the top in a booklet for general practitioners (!). 48 Seven sorts of hallucinations and delusions, which he referred to as “First Rank Symptoms,” were mentioned in this section. In addition to audible thoughts, voices disputing and/or debating, voices commenting, somatic passive experiences, thought withdrawal/influenced thinking, thought broadcasting, and deluded perceptions (the eighth symptom, “made volition,” was included in a later publication). When there is no question about their presence and no underlying medical illness can be discovered, we clinically talk in all humility about schizophrenia, according to Kurt Schneider.
However, due to world events like World War II, the book went mostly forgotten. Even after the war, when Kurt Schneider became the head of the University of Heidelberg, his idea to employ particular delusions and hallucinations for diagnosing schizophrenia had little influence. To make up for this lengthy lag time—which we’ll discuss further below—the “First Rank Symptoms” were suddenly well-received by American and international psychiatrists and gained prominence in classification systems 40 years after they were first published in the 1960s and 1970s thanks to several developments in psychopharmacology.
In the early 1930s, Kurt Schneider (1887–1967), a contemporary and admirer of Karl Jaspers (1883–1969), was director of the Clinical Unit of the German Research Institute for Psychiatry (Deutsche Forschungsanstalt für Psychiatrie) in Munich. Schneider’s “General Psychopathology” set a landmark for phenomenological descriptions of abnormal psychological phenomena. While he was more of a clinician than a researcher, publishing was scarce and his primary focus remained on didactics.
He created the above-mentioned pamphlet for general practitioners in 1939 after initially adopting the phrase “First Rank Symptoms” at a conference in Berlin in 1938. “To publish a short and scientifically not particularly highbrow article as a monograph, requires justification,” he writes in the preface. My rationale is that I believe I can accomplish my goal more effectively than by writing it down in a diary. My goal is to aid the doctor in establishing a mental health diagnosis. These recommendations are aimed at psychiatric diagnoses that rely only on psychopathological symptoms, such as schizophrenia and cyclothymia, for the general practitioner to make. Those diagnoses are routinely overlooked by general practitioners, according to my personal experience. I’d want to draw attention to some of the most common blunders that people make while trying to elicit and utilize psychopathological phenomena to make a mental health diagnosis. This book concludes with an effort to develop a rank order of psychopathological symptoms, which may also be of interest to psychiatrists.”.
Since “First Rank Symptoms” became an international phenomenon, “which might also be of interest to psychiatrists” is particularly noteworthy. In his own way, Kurt Schneider was a modest guy. As his book “Clinical psychopathology” (including the “First Rank Symptoms”) was released in 1950, he wrote to a colleague: “In truth, I do not trust longer in the accuracy of what I am teaching. I’m definitely at the stage that Jaspers refers to as “failure” now. 51 Later, he wrote to Karl Jaspers, “psychopathology plays only an insignificant role in today’s society, and in some hospitals no role at all” in response. 52
However, Kurt Schneider dissented from Eugen Bleuler by focusing on delusions and hallucinations and not discussing “basic symptoms” at all, but he followed him and differed with Emil Kraepelin by not providing any criteria for the length of schizophrenia. As a result, he did not believe in the existence of mental illness entities as Kraepelin had done, and urged to “free psychiatry from the slavery of neurology”—all in direct contrast to Kraepelin’s inclusion of “First rank symptoms” in the “Neo-Kraepelinean” DSM-III criteria.
In order to identify “practical types” of human responses, Kurt Schneider was a psychopathologist and a phenomenologist who focused on the patient’s inner psychological experiences. Patients who describe their hallucinations and delusions to their family doctors or other non-psychiatric health care providers may help general practitioners who lack specialized training and clinical expertise recognize schizophrenia. Jaspers had previously been critical of him in a letter dated 1923: “Methodological subtleties aren’t enough, one also has to show that it’s useful for something” (all quotes above are from52). This assessment is solely relevant to the diagnosis.” It says nothing about Bleuler’s “basic symptoms” and “accessory symptoms” concepts of schizophrenia… Other first-rank schizophrenia symptoms may also be recognized. But we limit ourselves to those that can be recognized without trouble” 53, p. 129). Validity is overshadowed by dependability! Those who have followed the evolution of operational diagnostic criteria from the 1980s and beyond must hear something.
DSM and ICD categorization systems have morphed schizophrenia into an atheoretical conglomeration of definitional pieces from previous descriptions that had never been conceived of as fitting together. According to Kurt Schneider’s critique of Kraepelin as a 19th century positivist natural scientist27, Eugen Bleuler’s accessory symptoms were raised to “first rank” symptoms following Kraepelin’s U-turn.
It should be noted from an anti-stigma perspective that “craziness symptoms” are prominent today in the symptom pattern of schizophrenia in operational diagnostic systems (although less so in more recent editions, where other symptoms, such as inactivity and thought disorde, are more prominent).22, 74
It is becoming more common to see dozens of individuals throughout the globe diagnosed with schizophrenia each year, but they want to conceal it from the public in order to escape the severe implications of a scientifically unfounded illness diagnosis. This is not to say that people do not experience one or more of the psychopathological phenomena or criteria included in the operational definition of schizophrenia at some point in their lives, sometimes for a brief period and other times for a prolonged period………………………………………….. Psychopathological events have led to the construction of the category illness entity “schizophrenia,” and the effects of this name on people’s lives are the issue.
People may quickly access information on these criteria because to millions of copies of various DSM editions that have been marketed to the general audience. According to “Schizophrenia DSM5 Definition—Schizophrenia is a severe and chronic mental disorder characterized by disturbances in thought, perception, and behavior”76, some websites do warn against “myths about schizophrenia,” while others propagate them. Some attempts are being made today to battle the stereotype, such as battling the notion of chronicity with recovery,77 education and renaming of the disorder45,77 the split personality idea with renaming and education and the implications of hallucinations and delusions with behavioral therapies. 80 and 81, respectively There is a strong sense that the categorical disease concepts of mental disorders are embedded in a hermetic professional system and the term schizophrenia will continue to be used without questioning it—in textbooks for educating medical students, in clinical guidelines for practitioners, in research (despite the fact that diagnostic algorithms produce heterogeneous groups of patients), in hospital payment systems (despite the diagn). Psychiatrists may utilize a variety of techniques instead of the illness entity “schizophrenia,” such as the multidimensional and person-centered approaches, or the usage of a vulnerability stress coping model. Given the medical nature of psychiatry and the uncertain future of the profession, it is not clear whether these practices can be embraced in a systematic way.
