David Hill readings reprinted from The Politics of Schizophrenia: psychiatric oppression in the United States 1983 (University Press of America 1983) with the permission of the author (currently not in print).
Chapter 11
EUGEN BLEULER: ADMITTING AND IGNORING THE PROBLEMS
Eugen Bleuler (1857-1939), working in Switzerland, apparently felt free to differ from Kraepelin on several counts, although he definitely adhered to the "fundamental idea" of a disease entity. He is, perhaps, best remembered for his emphasis on associational disturbances and splitting of the psychic functions--as compared to Kraepelin's prognosis of dementia--as the primary defining characteristics. He explains the title of his famous monograph, "Dementia Praecox oder die Gruppe der Schizophrenien' (1911), characterized by Zilboorg (1941) as "the classic work of twentieth century psychiatry" in the following manner:
The older form [dementia praecox] is a product of a time when not only the very concept of dementia, but, also that of precocity, was applicable to all cases at hand. But it hardly fits our contemporary ideas of the scope of this disease-entity. Today we include patients whom we would neither call "demented" nor exclusively victims of deterioration early in life. (1911, p.7)
I call dementia praecox "schizophrenia" because (as I hope to demonstrate) the "splitting" of the different psychic functions is one of its most important characteristics. For the sake of convenience, I use the word in the singular although it is apparent that the group includes several diseases. (1911, p.8)
Bleuler is also remembered for the notion of ambivalence--which ran contrary to Kraepelin's observations of flat affect, and for his creation of the term autism for "the highly personal associational chain of meanings for schizophrenics--meanings that were understandable only in terms of the developmental history of the individual."
The Inventor's Own Reservations
His alterations and additions, however, free him from few of the criticisms leveled at Kraepelin. The same circuitous logic is evident in his particular ver sion of the symptomatic approach and there is a similar lack of data to support his belief in a physiological etiology--singular or multiple. He is, nevertheless, even more willing than his predecessor to point out the tentativeness of all aspects of his theorizing. He is also far more willing to include the psychological and sociological in his thinking. On several occasions he even goes part way towards considering the social control perspective. In fact, the opening statement of Bleuler's monograph reads:
Our knowledge of the disease group which Kraepelin established under the name of Dementia Praecox is too recent to warrant a complete description. The whole complex is too fluid, incomplete, tentative. Since it would be rather tedious to draw attention to all the reservations implied by this fact, I hope I am justified in assuming that the reader will bear this in mind. (1911, p.1)
Nevertheless, Bleuler does repeatedly state serious reservations about the symptomatology, the prognosis, the etiology, the relationships between these three aspects, and about the disease process, the sub-types and treatment. They are cited here not only to give credit to Bleuler for being his own best critic, but because they provide a succinct summary of the problems that arise when one tries to transform a collection of deviant behaviors into a disease. It is doubtful, how ever, that Bleuler was justified in assuming that the reader would bear his reservations in mind. Because of the previously noted pressures psychiatry was too eager for conclusive statements and had little time for expressions of doubt. More importantly, the vast majority of people employing Bleuler's construct never had the opportunity to read his reservations. The monograph was not translated into English (or any other language other than its original German until 1950. For almost 40 years, during which time 'schizophrenia' became accepted as a disease that really existed, research and theorizing was undertaken in almost total ignorance of the following reservations expressed by its inventor.
In the attempt to explain this disease, we admittedly have to resort to hypotheses. we should not forget that, even in the event that all our hypotheses should eventually prove correct, we would still be acquainted with only a very small part of all the mechanisms which are probably involved in the symptomatology of this disease. (Bleuler, 1911, p.348)
We do not as yet know with certainty the primary symptoms of the schizophrenic cerebral disease. (1911, p.349)
The anatomical findings do not correspond with the severity of the manifest symptoms. (p.462)
Since schizophrenia may become stationary at any stage, continue to progress or develop acute symptoms, it is impossible to establish any definite, systematic outline of prognosis. (p.328)
It is impossible to describe all the variations which the course of schizophrenia may take. (p.328)
The pathology of schizophrenia gives us no indication as to where we should look for the causes of the disease. Direct investigation for specific causal factors has also left us stranded. (p.337)
It is not absolutely necessary to assume the presence of a physical disease process. It is conceivable that the entire symptomatology may be psychically determined and that it may develop on the basis of slight quantitative deviations from the normal. (p.461)
The present state of our knowledge does not permit us to establish valid etiological groups of schizophrenia. (p.242)
Let us openly say to ourselves and to others that, at present, we know of no measures which will cure the disease, as such, or even bring it to a halt. (p.472)
We do not know what the schizophrenic process actually is. (p.466)
Despite the pervasiveness and extremity of the problems generated by a medical framework, Bleuler's wondering about "what sort of entity the concept of dementia praecox actually represents" never actually includes the possibility that the construct might be more easily understood within a social control framework. The "fundamental idea" is never questioned. One cannot help but wonder what sort of problems would have had to be encountered before the question of the appropriateness of the medical model would have been considered.
How Not to Establish the Existence of a Disease
Unlike Kraepelin, however, Bleuler did feel the need to justify the manner in which he attempted to establish 'schizophrenia' as a disease entity. An examination of his thinking on this matter will facilitate our understanding some of the conceptual difficulties involved--then and now--in the medical view of 'schizophrenia' Bleuler begins by attacking the symptomatological concept of disease and then states his own criteria for determining whether a set of data constitutes evidence of a disease. I will argue, however, that not only does he fail to apply his criticisms and criteria to his own work, but that he consistently avoids the central issue: the absence of a proven physiological etiology.
We begin with his comments concerning the process of identifying a disease solely in terms of certain behaviors:
Not many symptomatological concepts of diseases have survived in other fields of medicine. Where no substitutes could be found for them, they are being employed in full awareness of the fact that they are merely temporary formulations, not diagnoses. Yet in psychiatry, such obvious conceptions must still be fought for. Of course, paresis is always proudly cited as the model of a clear-cut concept; it is, however, in direct contrast to the symptomatological conceptions of disease. . . . A concept built upon the basis of a single striking characteristic is always somewhat vague and arbitrary. . . . A symptom, regardless of whether it is psychic or physical (pain, anasarca) is never a disease; neither is a symptom-complex. (1911, pp.272,273)
Both the strength of his conviction that the arbitrary singling out or grouping of behaviors is a futile exercise, and his belief that everyone except Kraepelin and himself are the culprits, are evident from the following:
That such terms as confusion, acute paranoia, acute hallucinatory insanity, confusion mentale, as well as mania and melancholia in their ancient sense (in which they are still being employed in Enland and France) do not designate "diseases" should be clear to anyone who has observed mental patients. (1911, p.272)
Not only the names but the entire concepts . . were arbitrarily constructed by this or that observer, depending on which symptom he considered the most striking one. On this basis an actual delineation of such clinical pictures of disease is impossible. . It would take me far too long if I were to say all the unpleasant things which I really ought to say about these notions; and I am hardly equal to the task since I simply cannot understand those who believe that these terms connote actual concepts of disease. (1911, pp.27l, 272)
For similar reasons it would take the present author far too long to say all the unpleasant things which he really ought to say a bout Bleuler's notion. The extent to which we can understand his belief that the term "schizophrenia" connotes an actual concept of disease is determined by our understanding of the zeitgeist within which he worked and of the human propensity to isolate and control deviant behavior while engaging in benevolent sounding rationalizations to obscure that process.
Presentation of data substantiating the existence of that propensity in the work of both Bleuler and Kraepelin will follow. Let us first evaluate Bleuler's construct according to his own criteria.
We have to try to prove then: (1) that the various other diagnoses under which the Kraepelinian dementia praecox is usually classified do not represent any real concepts of disease, and (2) that the concept of dementia praecox substitutes something far better, a genuine concept of disease for the clinical picture. (1911, p.272)
More specifically:
We must ask ourselves the questions: In what connection with other symptoms and anatomical findings, in what sort of course, as the result of which causes does the symptom appear? Perhaps we must also ask what fundamental disturbance is the basis for this symptom? Only the answers to these questions can provide us with the concept of the disease. (1911, p.273)
Bleuler's notion of 'schizophrenia' fails to answer each and every question which he himself states must be answered before one can claim the existence of a disease.
His first criterion is some consistent relationship between symptoms. More telling than his doubts as to what constitute the primary symptoms, than his statements concerning the extreme heterogeneity of the symptomatology, than his admission concerning the overlap of symptoms with other diseases, are his criticisms of the symptomological approach per se. In the very same paragraph that he cites the inter-connection of symptoms as his first criteria he has already stated that a symptom "is never a disease; neither is a symptom complex"!
His second question is concerned with what sort of connection exists between symptoms and anatomical findings. In evaluating the extent to which the notion of schizophrenia answers this question, we can refer to Bleuer's own statement that "the course of the symptoms and the course of the disease process need not run parallel to each other by any means" and to "the fact that the anatomical findings do not correspond with the severity of the manifest symptoms."
In asking the question "what sort of course?" one might assume that the criterion implied is that of relative consistency. We have previously noted Bleuler's statement that the course of schizophrenia is so unpredictable that the variations defy description. If, however, we interpret the question as implying the criterion of a consistent relationship between course and symptomatology, we should realize that Bleuler, himself, admits that "we have not discovered any correlation between the initial disease symptoms and the severity of the outcome of the illness" (1911, p.261).
"As the result of which causes does the symptom appear?" Bleuler is quite honest about his inability to answer this question. We should remember that he even goes so far as to state that "the pathology of schizophrenia gives us no indications as to where we should look for the causes of the disease."
Perhaps the only one of his questions that Bleuler even comes close to answering is that concerning the fundamental disturbance. His entire theory is built on the notion that disorders of the associational processes and splitting of the psychic functions (e.g., thoughts from feelings) are, in some way, primary. Employing the ability to identify "the fundamental disturbance as a criterion for establishing a disease entity is questionable on two counts. First, one might wonder whether Bleuler is guilty of what he, himself, identifies as a culpable offense in arbitrarily singling out a particular set of behaviors by which to define the construct. As he has said, another observer might focus with equal arbitrariness on some other set of behaviors. He might offer the 'mitigating circumstance' that he is discussing a disturbance and not a symptom. How one differentiates the two is beyond the understanding of this author, but it seems that Bleuler believed associational deficits and splitting of functions to be causative agents, in some way responsible for other symptoms. His statement that "the absence of the 'feeling of familiarity' with known things . . . is usually attributable to a deficit in customary associations" clearly expresses such a belief, and is just one of many similar examples.
Bleuler appears, here, to be attempting to follow the well established, but futile, process of grouping supposedly similar behaviors, arguing that one subset is somehow primary and that the remaining subsets are therefore subordinate to, or caused by, the former. It is of interest that,referring to "schizophrenics", but not himself, Bleuler states that "associations formed in terms of habit, similarity, subordination, causality, etc., of course will never generate truly fertile thoughts (1911, p.16)!
How, then does Bleuler assume to demonstrate "that the concept dementia praecox substitutes something far better, a genuine concept of disease for the clinical picture"? The answer is, perhaps, to be found in that very term "clinical picture". In the same manner as Kraepelin, Bleuler creates the illusion of a substantive theory by arguing that no particular aspect--the symptoms, the etiology, the prognosis--can, in isolation, support the existence of a disease entity. Nevertheless, when these aspects are integrated and cross-referenced, one is supposed to recognize undeniable evidence of a disease entity.
In such a process, the absence of a proven etiology is transformed from a severe problem to a definite advantage. As previously noted in reference to Kraepelinian thinking, without the restraints of a specified etiology, one is free to explain any and all theoretical flaws and logical inconsistencies by reference to the undefined "disease process". For instance, Bleuler attempts to explain the fact that different 'catatonics' exhibit different symptoms by reference to an unspecified etiology:
A number of symptoms were designated which at the time helped to formulate a definite conception of catatonia. They may readily occur singly, but it is not improbable that they nevertheless have an inner connection in the sense that they occur most frequently with a certain condition of the brain that is at the foundation of catatonia. (1924, p.403)
The tendency for onset to occur during adolescence is explained by such sophisticated concepts as an acute "pathological thrust" (1911, p.463), and the anthropomorphic notion that "the actual disease process may show a preference for the post-pubescent period" (p.464).
When one adds to an undefined physiological etiology the notion of latency and the argument that some symptoms may be psychogenic in origin, the presence, or absence, of just about any behavior under the sun can be considered a symptom of schizophrenia. Bleuler argues, for instance, that the extreme heterogeneity of symptoms does not constitute a problem for the disease notion, since it is the content of the symptoms and not the symptoms themselves which account for the major part of the variance; and the content is determined by psychological factors, not by the disease process. Similarly, "aggrevations and improvements in the patient's condition are often psychically determined" (1911, .462). When variations in symptoms and outcome are explained psychogenically the "disease process" itself remains an inviolate construct, isolated from the observable data, accountable to nothing but the imagination of Eugen Bleuler. And his inventiveness--in order to further reduce any remaining misgivings about the heterogeneity of behaviors and variability of outcomes--includes the argument that while "the course of cerebral disorder is chronic . . . there are also phases of acute forward thrust or of standstill" (1911, p.463). (We should note that with characteristic honesty, Bleuler later admits that "we are as incapable of explaining the variations in disease qourses and disease groups on the basis of the patients' psychic predispositions or their psychic experiences, as we are of explaining them on the basis of some assumed disease process.")
Of course, Bleuler was not trying to deceive us. His theorizing is based
on the sincere belief that a physiological etiology would one day be discovered.
Such an etiology would indeed be discovered many times between then and
now, and, on every occasion, be rejected after a few years. The search continues
to this day.