Eugen Bleuler and the Schizophrenias: 100 Years After

Bleuler’s pioneering work on schizophrenia still has strong relevance nowadays, thus the 100th anniversary year of the publication of his seminal work Dementia Praecox or the Group of Schizophrenias^1,2 represents a good opportunity to reexamine his breaking-thought ideas about the disorder such as their validity in the light of the current knowledge. The present series of articles together with a study recently published in the Bulletin on the same topic³ seeks to elaborate how Bleuler’s ideas on schizophrenia have influenced our understanding of the disorder and how may inform on future developments.

It must be first acknowledged that, for several reasons, examining Bleuler’s ideas on schizophrenia is not an easy task. While the monograph Dementia Praecox or the Group of Schizophrenias represents the main source of Bleuler thoughts on schizophrenia, it is not the only one, since Bleuler commented and developed his ideas in a number of articles^4–6 and in his textbook, which underwent 6 editions during Bleuler’s life.⁷ Furthermore, Bleuler’s position on schizophrenia from the inception of the concept until his death in 1939 shifted in some aspects. The 15th and last edition of Bleuler’s textbook was published in 1983 and was coauthored with his son Manfred Bleuler.⁸ This edition contains substantial modifications of the original concept of schizophrenia as entailed in the 1911 monograph. All together, Bleuler’s work on schizophrenia is multilayered and complex; and while reflecting a strong integrative trend, it seems fragmented and contradictory at times. For example, the fundamental vs accessory distinction of symptoms becomes logically contradictory when applied to diagnosis because Bleuler considered some accessory symptoms such as certain auditory hallucinations of diagnostic value. A further difficulty is that Bleuler ideas have been often interpreted in different ways from different authors.^9–14

Moskowitz and Heim (May issue)³ highlight several contextual, conceptual, and methodological issues related to the development and interpretation of Bleuler’s ideas on schizophrenia. In the first part of their article, Bleuler’s methods are contrasted with Kraepelin’s, which shed considerable light on Bleuler concepts, ideas, and hypothesis about schizophrenia. Basically, the main authors’ contention is that Kraepelin, heavily influenced by the natural sciences, developed a psychiatric nosology from preconceived notions in an inductive fashion; whereas Bleuler, by examining his patients very carefully and closely, utilized a deductive methodology. In the second part of their article, the authors revise 4 myths about Bleuler’s conceptions, namely, that Bleuler’s “schizophrenia” and “splitting” refer narrowly to a separation of thought and affect or a splitting of associations, that “loosening of associations” can be equated with a fundamental disturbance of thought, that Bleuler’s teaching on schizophrenia can be adequately summarized by the 4 A’s—association, affectivity, ambivalence, and autism, and that Bleuler’s conception of schizophrenia reflects a significant impact of Freud thought. By refuting these myths, the authors come to the conclusions that Bleuler’s concept of schizophrenia is closely linked to historical and contemporary concepts of dissociation, that Bleuler’s concept of loosening of associations refers broadly to a core organically based psychological deficit that underlies the other symptoms of schizophrenia, that the 4 A’s rule is a misnomer that marginalize the central role of splitting, and that Bleuler’s ideas were more powerfully influenced by Pierre Janet than by Sigmund Freud. The last conclusion, however, sharply contrast with that of other authors¹⁰ that have underlined the marked influence of Freud ideas on Bleuler’s conception of schizophrenia. This influence was also acknowledged by Bleuler himself in the introduction of his monograph, and Manfred Bleuler considers that “the main contribution of Eugen Bleuler to the problem of schizophrenia was to favor the study of what was going on psychodynamically in a schizophrenic patient.”¹⁵

Josef Parnas¹⁶ (in this issue) remind us that the “trivial” question of what is schizophrenia? is not the question of a pathognomonic symptom but rather of a characteristic Gestalt. According to the author, there exists a core Gestalt of schizophrenia, which manifests itself through the fundamental symptoms, a structural change of subjectivity, and the “praecox feeling”. Parnas considers that Bleuler’s fundamental symptoms overlap each other and that autism, the prime fundamental symptom, contains aspects of affect, association, and ambivalence. The author develops a fine and original approach to autism integrating several dimension of the construct such as withdrawal to fantasy life, the subjective dimension, and a crisis of common sense. In summary, the clinical core of schizophrenia manifests itself as a Gestalt emerging across a manifold of symptoms and signs, which may occur in all domains of mental life and are only partially captured by the operational definitions of schizophrenia. This work illustrates how Bleuler may be considered within a continental European tradition of psychopathologists that considered schizophrenia has a prototypical clinical core with phenomenological reality and an intersubjective nature, which is irreducible to single symptoms or signs. This notion is in line with Manfred Bleuler contention that “decisive for the diagnosis of schizophrenia was for Eugen Bleuler never one or several individual symptoms but the whole psychopathological picture together with the circumstances under which the syndrome has developed.”¹⁵

Stephan Heckers¹⁷ (in this issue) focuses on Bleuler thoughts on the neurobiological basis of schizophrenia. According to Heckers, while Bleuler assumed a neural basis for schizophrenia, he remained extremely tentative on possible mechanisms and the value of pathological diagnosis. Furthermore, Bleuler clearly preferred psychological understanding over neural explanation. Notwithstanding this, Heckers underlines that Bleuler’s assumed that psychological process of schizophrenia maps to a cerebral process. Bleuler’s ideas on schizophrenia have been updated by Andreasen within a neo-Bleulerian neurocognitive model,¹⁸ in which schizophrenia is defined as a “misconnection syndrome,” involving a cortico-cerebellar-subcortical circuit disruption that leads to misconnections in many aspects of mental activity, or “cognitive dysmetria”. According to Andreasen, cognitive dysmetria represents a more general concept of loosening of associations—in a similar sense as pointed out by Moskowitz and Heim.³ Supporting this view, and despite the above mentioned lack of diagnostic specificity of formal thought disorders, they appear to be among the phenotypic candidates more closely linked to neural circuitry disruption.¹⁹

Loosening of associations is of particular relevance in Bleuler’s model of schizophrenia because this symptom is intended to be primary—close to the organic substrate of the disorder, and fundamental—always present over the illness course. Thus, according to Bleuler, formal thought disorders would be of paramount pathological and diagnostic importance. Cuesta and Peralta²⁰ (in this issue) address the specificity issue of formal thought disorders for schizophrenia-spectrum disorders and major mood disorders, and more specifically, they tested the hypothesis recently advanced in the Bulletin by Lake²¹ that formal thought disorders are severe mood disorders. The authors found that formal thought disorders are a multidimensional construct comprising at least 5 domains: disorganized speech, verbosity, poverty of speech, idiosyncratic thinking, and blocking. The disorganized speech factor was the most relevant component of thought disorders and appeared to entail the essential components of Bleuler’s loosening of associations. While severity of formal thought disorder components significantly differed across diagnosis, no one factor was specific to a given disorder. These findings do not support neither Bleuler’s nor Lake’s hypotheses; in fact, they support the consideration of formal thought disorders, and particularly disorganized speech, as a relative unspecific syndrome within psychotic and major mood disorders.

It is difficult to outline the main contributions of Eugen Bleuler to our current understanding of schizophrenia. Acknowledging that, to some extent, this is a subjective task, we would mention the following 7 main contributions

1. The Bleuler monograph remains as the more comprehensive psychopathological description of schizophrenia. Bleuler not only emphasized the clinical richness of schizophrenic psychopathology but he has become a model for careful clinical observations of the whole spectrum of experiences, symptoms, and signs of the patients, which comprise an enduring contribution to clinical psychiatry. In fact, this text continues to be a reference for students, clinicians, and academicians.

2. Bleuler undermined the nosological entity hypothesis of Kraepelin’s dementia praecox. Bleuler saw schizophrenic psychopathology as a continuum of severity that ranges from schizoid personality and latent schizophrenia to schizophrenia. He, therefore, advanced the current concepts of schizotypical traits and disorder and their relatedness to schizophrenia, such as the concept of schizophrenia-spectrum disorders. Bleuler conceived of schizophrenias as genus rather than a species—hence his title, The Group of Schizophrenias, and broadened the borders of the disorder in relation to both nonpsychotic disorders and other psychotic disorders.

3. In connection with the former point, Bleuler acknowledged that the outcome of the disorder is extremely varied—a matter of fact according to current knowledge, and therefore, he contributed to avoid a nihilistic view of treatment.

4. Bleuler was the first to draw the attention to the psychological inner life of the patients in the realms of cognition, affectivity, and subjective experiences. Where others saw dementia and bizarre thoughts and behaviors, Bleuler tried to see the emotional life of the patients and attempted to link it to their biography and social context. This added a new psychological dimension to treatment and created a basis for a psychotherapeutic and psychosocial approach that Bleuler himself tried to implement in his patients by means of a strong therapeutic alliance, psychoeducation, and rehabilitation of the altered functionality.

5. While Bleuler assumed that schizophrenia lies in a brain dysfunction and an inherited disposition, he also pointed out the relevance of biographical and environmental factors in the etiology of the disorder. He also acknowledged that psychological factors that he believed influenced secondary symptoms, map to a cerebral process and tried to disentangle the complex relationships between biological and psychosocial factors in causing symptoms and the disorder. This is a key concept in Bleuler’s model of schizophrenia, for which he deserves to be recognized as the forerunner of modern theories such as the vulnerability stress and the gene-environment interaction models.

6. Bleuler described the sparing of cognitive functions in schizophrenia and distinguished the neurocognitive impairment, which was closely linked to the splitting of psychic functions, from that observed in the organic dementias.

7. Finding a unifying concept behind the diversity of signs and symptoms in schizophrenia is a central challenge to contemporary research. Bleuler tried it by means of the fundamental-accessory and primary-secondary distinctions of schizophrenic symptoms. Whereas this classification has been considered as highly speculative, it posses potential heuristic value and has never been formally tested. Interestingly, the primary-secondary and the enduring-transitory classification of negative symptoms²² appears to be highly reminiscent of Bleuler’s classification of schizophrenic symptoms. Given that the deficit syndrome—defined as comprising primary and enduring negative symptoms—has proved to have substantial predictive value,²³ why not to define other domains of psychopathology such as reality distortion and disorganization in the same way and test their validity? The example of deficit symptoms shows that Bleuler’s classification of symptoms continues to be an unexplored and potentially fruitful approach for disentangling the etiopathological and clinical underpinnings of the disorder.

Funding

None.