One Hundred Years

Eugen Bleuler published Dementia Praecox or the Group of Schizophrenias in 1911. The Bulletin takes note of this remarkable contribution with a perspective in this issue provided by Andrew Moskowitz and Gerhard Heim.¹ Later this year, we plan to publish theme articles marking progress within the Bleulerian framework and modifications based on accrued knowledge. Victor Peralta and Manuel Cuesta are organizing this material. A commentary at that time will provide a historical perspective by German Berrios. We hope to remind the field of Bleuler's remarkable contribution and increase understanding of his place in our history and his influence on our present endeavors.

I trained in psychiatry in the early 1960s, not long after the English translation of Bleuler's book was published in 1950. The influence was substantial, and emphasis was given to disordered thought and how schizophrenia thought process was phenomenologically distinguished from normal thought on the one hand, and manic-depressive psychosis and delirium on the other. Rorschach cards provided an informative stimulus for observing disordered thought and were used in the remarkable family studies of Wynne and Singer² and the development of the Thought Disorder Index by Holzman.³ There was, perhaps, less attention to avolition and reality distortion as characteristics of the disorder. The former had been central to Kraepelin's concept of dementia praecox. Giving credit to Bleuler for describing dissociative thinking as being central to the construct now called schizophrenia, Kraepelin postulated that the combination of avolition with dissociative pathology was the essential characteristic of cases. The latter, reality distortion pathology, was emphasized as an expression of psychosis but not critical to differential diagnosis. But this was soon to change in North America as it already had in the United Kingdom and much of Europe. Schneiderian symptoms of first rank were soon to be the cornerstone for diagnosis.

Fish's little blue book summarized Schneider's approach to schizophrenia in English.⁴ I had read the book as a resident, but the profound influence of his teachings became clear to me while participating in the International Pilot Study of Schizophrenia (IPSS)⁵ about 1968-1973. Most IPSS collaborating investigators were accustomed to First Rank Symptoms (FRS) representing the presence of schizophrenia, and Wing's CATEGO program assigned cases to “nuclear schizophrenia” if FRS were scored positive on the Present State Exam.⁶ Collaborating investigators from Moscow and Washington were the apparent exceptions. What was surprising at that time was the absence of empirical studies of the role of FRS in diagnosis and prognosis. Reports from the Washington center suggested that FRS were not decisive for diagnosis or prediction of outcome.^7–9 At that time, we also reported that restricted affect, poor rapport, and poor insight were the most distinguishing features (among psychotic disorders) of schizophrenia.¹⁰ Despite these and other data, the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, (DSM-III) brought reality distortion symptoms to prominence in the A criteria for a diagnosis of schizophrenia and omitted negative symptoms such as restricted affect and avolition from criteria. Special emphasis was given to FRS where a single bizarre delusion was sufficient to meet the A criteria.

We have argued elsewhere that this shift away from avolition and dissociative pathology toward reality distortion represented a fundamental alteration in the schizophrenia concept.¹¹ At a time when the perceived broadness of the diagnosis as used in the eastern United States needed to be corrected, DSM-III moved away from the pathologies defined by Kraepelin and ignored Bleuler's view that dissociative pathology was both primary and fundamental. Reality distortion pathology, viewed as accessory/secondary by Bleuler, now gained primacy in diagnostic criteria for schizophrenia (see Moskowitz and Heim, this issue, for an informed discussion of Blueler's views).¹

Although the DSM-IV included negative symptoms in the A criteria, diagnostic threshold could still be met with hallucinations and delusions alone, or even just a bizarre delusion without other symptoms associated with the concept. However, the shift of the concept toward reality distortion resulted in a diagnostic category that identifies not a disease, but rather a heterogeneous clinical syndrome. It does not assure similarity between cases beyond reality distortion pathology. This has profound consequences in that the drug treatments developed over the past 60 years for schizophrenia have produced agents with antipsychotic effects targeting reality distortions across diagnostic boundaries without discovery of therapeutics for avolition, impaired processing of emotion, or psychomotor abnormalities.

This has been the impetus for efforts to define domains of pathology^12,13 and the field's receptiveness to including dimensions of pathology in addition to diagnostic class in DSM-5 (http://www.dsm5.org). If implemented, DSM-5 will systematically call attention to the symptom domains that are the targets for clinical management and therapeutics. Patients with schizophrenia may [or may not] be depressed, anxious, manic, thought disordered, avolitional, or cognitively impaired. Such dimensions will also help clarify the porous boundaries between syndromes. And the opportunity to map psychopathology onto neural circuits as proposed in the NIMH Research Diagnostic Criteria initiative will be enhanced.¹⁴

Looking back a 100 years to Bleuler's seminal contribution fills one with admiration and appreciation. There is depth in his experience with persons afflicted with schizophrenia, and a creative intelligence in his description and formulation that may be unparalleled in the history of psychopatholgy.