Eugen Bleuler (1857-1939) and German psychiatry

Eugen Bleuler was born 150 years ago, and about 100 years ago he published his "Schizophrenia" for the very first time-giving rise to a retrospective view especially concerning German psychiatry. Together with Emil Kraepelin, who was more or less of the same epoch as Freud, E. Bleuler is one of the fathers of modern psychiatry. From the broad spectrum of his psychiatry with many findings, two achievements are particularly meaningful: the schizophrenia monography of 1911 and the first edition of his educational manual from 1916. Psychiatry owes two achievements to E. Bleuler: "deepened" psychopathology, which depicted schizophrenic symptoms and their relation, and the importance of psychoanalysis for psychiatry. Bleuler was not a psychoanalyst himself but rather a pluridimensional psychiatrist in the best sense of the word and at the same time sympathetic to psychoanalysis. The reception and historical effect of Bleuler's work are described. Another important subject that Bleuler himself regarded as the central field in his work is pointed out: the fight against alcoholism.     

DSM-5中关于精神分裂症诊断标准修改的建议

目前对于精神分裂症的概念源自19世纪末埃米尔.克雷丕林对早发性痴呆的阐述及20世纪早、中期尤金.布洛鲁勒和柯特.施耐德的贡献。克雷丕林主要是根据病程（逐步恶化）和结局（痴呆或＂精神迟钝＂）识别出早发性痴呆。尤金.布鲁勒重新命名为＂精神分裂症＂,     

Simple schizophrenia: past, present, and future

The diagnostic category called simple schizophrenia has disappeared from official American nosology but has been retained in ICD-9. The diagnosis has a long history, was one of the traditional schizophrenic subtypes identified by Bleuler, and was later accepted by Kraepelin. The authors provide a historical overview of the concept, review its modern successors, and provide recommendations for its inclusion in DSM-IV as a proposed diagnostic category needing further study.     

The history of schizophrenias: philosophical roots

Although the term "schizophrenia" has been introduced in medical usage by E. Bleuler, all variations of schizophrenia developed afterwards trace back to E. Kraepelin. In his work on dementia praecox he intended to discover a yet unknown entity from nature definitely following the principles and maxima of positivism. In the following a great number of different concepts of schizophrenia were developed and the psychiatrist of the seventies and eighties of the last century was left confronted with an abundance of varying schizophrenic criteria. The upcoming globalization in diagnostic stopped this process of diversity and the ideas of Kraepelin reappeared in the ICD-10 criteria for schizophrenia with only a few modifications. The main problem of positivistic research approaches is that nature obviously is completely unimpressed by human made principles of rules and systems. Nature itself does not know these forms and categories invented by human beings. That is one of the reasons why positivistic schizophrenic research considering human made categories as natural has not been quite successful. A possible way out of this diagnostic dilemma -- insufficient categorical classification systems on the one hand and the necessity of apprehending psychopathological phenomena for an effective therapy on the other -- can be a change of paradigms from the usual categorical diagnostics based on the maxima of positivism to dimensional diagnostics developed in the frame of post-modern strategies of thinking. Such process-oriented diagnostic approaches considering the singular phenomenon as well as its significance for the individual and its pathogenesis as main foci of diagnostics provide the possibility for post-modern psychiatrists to start a new dialogue overcoming a positivism based monologue made by experts on the sufferers.     

Whence dementia praecox and schizophrenia?

Described by Kraepelin and Bleuler, dementia praecox and schizophrenia have become the basis of psychiatry. At the XIXth century, this psychosis did not exist. The author attempts through a bibliographical review of the XIXth and XXth century psychiatric tests to delineate the lack of basis for this nosographical concept, which has become a juvenile psychosis evoluing to a dementia because of abusive generalisation of Kraepelin. The use of this bad diagnostic tool had made terrible damage with delusional and hallucinated adolescents and their family (Acta psychiat. belg., 1982, 82, 243-276).     

Evolution of diagnostic criteria for schizophrenia

Many operational diagnostic criteria for schizophrenia, which are rooted to various degrees in the concepts of Kraepelin, E. Bleuler and K. Schneider, have been developed during the last two decades. They often incorporate prognostic factors to which Langfeldt in particular had drawn attention. These recent criteria vary considerably according to the attitude taken with regard to Jasper's hierarchical principle, which accords a diagnostic superiority to schizophrenic symptoms over affective symptomatology. Attribution to schizophrenia is very different depending upon whether the systems uphold, reject or reverse this principle. One should distinguish between classifications based upon a consensus of experts or experienced clinicians on the one hand and diagnostic research criteria destined to test etiopathogenetic hypotheses on the other. The important principles of attribution of DSM III and DSM III-R are outlined as well as their shortcomings, the latter leading to the conclusion that one should not restrict oneself to employ solely the American classification, but utilize it along with other classifications, such as the French empirical criteria or the Vienna research criteria, in order to see more clearly whether the very broad definitions of schizophrenia do not camoufly particular etiopathogenetic entities which ought to be identified.     

The patient with schizophrenia and his father. The father's role and personality traits in the dynamics of the family with a son suffering from schizophrenia

The role of the father in the onset and development of schizophrenic disorder/disturbance is very often secondary as compared to that of the mother. This study deals with the father's sphere in the family with a patient/son suffering from schizophrenia, the traits of his personality and his relationship with his son/patient, and with his wife/the mother of the patient. The methods applied were clinical interview, structured interview and semantic differential. The following statistical procedures were used: correlation, componential, discriminative, factor and quasicanonical analyses. The results include some characteristic excerpts from clinical interviews with patients/sons and their fathers, projective perception of current family relationships, quasicanonical analysis of the father's, mother's and son's experiences of the patient's/son's early childhood, and the projective view of the father. Among the conclusions reached, the phenomenon of "dead father" is emphasized as one of the main factors in the onset and development of schizophrenic disorder/disturbance.     

Some aspects of order and symbolism in schizophrenia.

Developing out Rümke's term of "PraecoxGefühl", it is described that the schizophrenic disorder in his way of being is the fundamental underlying reason for dissociation of his thoughts and feelings. This consequently leads to a distortion in his system of sign recognition and the meaning attached to the different semantic and syntactic levels. By means of the "Wahnarbeit" and other mechanisms the schizophrenic tries to build another order in which he can feel more at ease with his overwhelming experiences. The conceptualization of his thoughts is performed by using a "principle of symmetry"--attaching the meaning of one perceived object (I) of reality to another conceptualized object (II). Very often we are unable to understand the individualistic nature of schizophrenic symbolization because of this mechanism.     

Discovery of the "deep personality" and revision of the Kraepelin concept of autonomic mental disease

It is necessary to make a revision of the conception of Kraepelin about schizophrenia and autonomic mental disease. The aim of Kraepelin was to discover an autonomic mental disease like the general paralysis: that was the dementia praecox. It is now impossible to prove this conception. The schizophrenia of Bleuler is characterized by psychic dissociation. Before Bleuler, Moreau de Tours described psychic dissociation not as a mental disease but as a reaction to toxic causes. The new researches about catatonia pointed the exactitude of Moreau de Tours's conception. Behind the apparent dissociation persist a personality that is still living and which it is possible to help and to treat with etiologic treatments and with moral comprehension.     

The work of Emil Kraepelin and his research group in München

Emil Kraepelin is well known due to his development of the psychiatric classification. The ICD-10 and DSM-IV classification is based on the dichotomy of endogenous psychoses into affective psychoses and schizophrenia as early as 1899. Moreover, beside his classification system he put enormous impact on the development of psychiatry to an empirical field of science. The research activities of Kraepelin and his coworkers show that he was not only the most active researcher in the field of psychiatry in his time but also that his research activities included a lot of clinical and experimental work in different disciplines of psychiatry, including psychology, pharmacology and natural sciences as 'Hilfswissenschaften'. Due to his extraordinary position also in his time he brought together important researchers of this time, in particular after the foundation of a psychiatric research institute. Alois Alzheimer, Franz Nissl, Robert Gaupp, or Korbinian Brodman are only a few of his well known coworkers. Kraepelin tried to bring foreward the empirical knowledge in psychiatry, he did not want to have cessation in psychiatry in general and in the classification of psychiatric disorders in particular. He discussed and partly revisted his view and his theoretical approach in the different editions of his textbook according to the state of his empirical knowledge. This is also true for the dichotomy. More than twenty years after the 6th edition of his textbook, he wrote in an essay 'Die Erscheinungsformen des Irreseins' ('The manifestations of insanity') regarding the dichotomy: "No experienced diagnostician would deny that cases where it seems impossible to arrive to a clear decision, despite extremely careful observation, are unpleasantly frequent." and "....therefore, the increasingly obvious impossibility to separate the two respective illnesses satisfactorily should raise the suspicion that our question is wrong". This contribution shows that Kraepelin himself questioned his dichotomy of dementia praecox and manic depressive insanity, a discussion which is lively still today--more than 80 years later.     

Motivation, volition, and ambivalence: A contribution to understanding of long-term impairments among schizophrenic patients

Traditional concepts of avolition (Kraepelin) and ambivalence (Bleuler) among schizophrenic patients can be interpreted in the light of present ideas of motivation and volition. Accordingly schizophrenic patients are marked both by oppositional high hope and fear components of implicit motives and by the impairment of volitional selfregulation, which both are vulnerability factors. In an environment lacking stimuli the patients cannot surpass their ambivalence through volitional selfregulation and remain passive. In this study 61 schizophrenic patients are compared with a control group of 69 non-patients. As expected, the schizophrenic patients show significant higher fear components of the implicit affiliation, achievement, and power motives, as well as an increased hope component of the affiliation motive. The comparison of subgroups of schizophrenic patients with distinguishing symptoms reveals no differences, which supports the assumption of stable traits.     

Folie à deux in schizophrenia--"psychogenesis" revisited]

OBJECTIVE AND METHOD: Since the 19th century, many studies have reported on folie à deux (FAD) in subjects with endogenous psychosis. However, the etiology of FAD in patients with schizophrenia has remained unclear, primarily because the possible psychogenic or reactive mechanisms of delusional contagion supposed in FAD were not compatible with the classical concept of endogenous psychosis. However, possible psychogenic mechanisms of FAD in schizophrenia were argued by Bleuler, E and Bleuler, M. The problem of how to distinguish the endogenesis from the psychogenesis (reaction) in FAD results in an aporia well-discussed in the German-speaking psychiatry: how induction in endogeneous psychosis might be possible? In the present study, first, a case of FAD in a husband and wife both with schizophrenia was reported. Three case reports of FAD in schizophrenic married couples from Japanese literature were also examined and the concept of the mind which lies in the background of psychogenesis/endogenesis dicotomy was discussed. CASE REPORT: A 34-year-old housewife had constructed a persecutory delusion shortly after the death of her father. She became convinced that her relative who was a Yakuza (Japanese Mafia) member was planning to kill her. She also reported auditory hallucinations. Her 41-year-old husband, who had been diagnosed with schizophrenia six years before the incident, first denied the claim of his wife that she had become a target of the Yakuza. However, shortly after that, he came to be convinced that he had become a target of another Yakuza. The couple took refuge in the husband's parents' home. Nevertheless, each of them thought that only he or she would be assassinated and not his or her spouse. After hospitalization, the husband was separated from his wife and soon recovered from his delusional state. However, the wife partially kept her persecutory delusion and full insight into her mental disorder could not be obtained after treatment. According to Gralnick's definition and sub-classifications of FAD, this case was diagnosed as FAD, subtype of "folie induite". DISCUSSIONS: Observed delusions of folie à deux in schizophrenic couples were classified into the following two categories, based on the subjective pronoun of the delusional statement: 1) We-type: "We are persecuted", generally observed in cases of paranoid type schizophrenia, paranoid disorder, and shared paranoid disorder; 2) I-type: "I am persecuted", observed in cases of non-paranoid schizophrenia in particular. It could be argued that the We-type suggests the establishment of a delusional community within participants not seen in the I-type delusion. However, according to clinical observations, even in We-type delusion, subjects ignored the wills and thoughts of their partners and somehow constructed the delusional community in a somewhat one-sided and egocentric way. In both We-type and I-type delusional formation, true communication was not established because of the limitation to the solipsistic view point inherent to the subjects involved. Therefore, we designated the We-type delusional view point as Paranoid Solipsism in FAD and the I-type as Schizophrenic Solipsism in FAD. According to German traditional psychiatry, We-type Paranoid Solipsism may correspond to "psychogenic" delusional formation mechanism and I-type Schizophrenic Solipsism to "endogenous" mechanism. The structural similarity between Paranoid Solipsism and the Husserlian concept of transcendental ego was also discussed. The author suggested that classical "psychogenesis" theory in psychiatry was founded on the modern concept of mind, which is inseparable from the European philosophical tradition of self-concept by Descartes and Husserl. From the Japanese literature, the author pointed out that the majority of FAD cases in Japan took the form of possession psychosis until the 1970's, and that We-type and I-type delusional formation in FAD appeared only after the late 70's. The implication of these transformations of FAD phenomenology in accordance with social structure change was briefly discussed regarding the relationship between the modernity and FAD delusion.     

Machado de Assis's epilepsy.

Machado de Assis (1839-1908) is considered the most important Brazilian writer and a great universal literary figure. Little is know about his medical, personal and family history. He hid his "disease" as much as possible. Machado referred to "strange things" having happened to him in his childhood. He described seizures as "nervous phenomena", "absenses", "my illness". Laet observed a seizure and described it as: "... when Machado approached us and spoke to me in disconnected words. I looked at him in surprise and found his features altered. Knowing that from time to time he had nervous problems, ... and only permitted Machado take the Laranjeiras Street car, when I saw that he was completely well". A photographically documented seizure is shown. Alencar wrote, "The preoccupation with health was frequent: either he was having the consequences of a fit or was foreboding one". It is clear that Machado presented localized symptomatic epilepsy with complex partial seizures secondarily generalized of unknown etiology. The seizures which began in infancy or childhood had remission in adolescence and then recurred in his thirties and became more frequent in his later years. His depression got markedly worse with age. In our opinion, the greatest consequence of Machado's epilepsy, was his psychological suffering due to the prejudice of the times. Despite this Machado showed all his genius, which is still actual and universal.     

"This time the reviewer is proud and pleased to agree with Kraepelin's latest nosology, since it is his own"

This paper aims to acknowledge the major impact Leipzig neurologist and psychiatrist Paul Julius M?bius had on the classification of nervous and mental illnesses. His main objective was to differentiate them by their underlying cause. Between 1890 and 1893 he sampled his views for both subjects. Expanding Evariste Marandon de Montyel's ideas of 1889 M?bius not only agreed that illnesses can emerge from causes that lie mainly within the body as well as mainly outside it, he even went as far as to say that there were illnesses that are solely based on causes outside the body. Moreover, it was M?bius who first introduced the terms "endogenous" and "exogenous" diseases. In accordance with the degeneration theory of his time he referred to transmission as the only etiological factor for endogenous illnesses, proposing that the extent of the illness is determined by the degree of degeneration. In the case of exogenous illnesses, however, the various stimuli affecting the nervous system would lead to qualitatively different illnesses. It is mainly due to Emil Kraepelin, who took over M?bius's dichotomy in the fifth edition of his most influential textbook of psychiatry of 1896, that his views had a lasting influence. And as it shown in the present study it was both through personal arguments with his old friend from Leipzig as well as through M?bius's equally critical and reprimanding reviews of the individual editions of Kraepelin's textbook that the latter acknowledged the importance of the etiological factor in his multi-factorial clinical and empirical nosology. However, since M?bius only considered etiological causes and neglected all others one should refrain from renaming, as suggested, "Kraepelin's nosology" as "Kraepelin's and M?bius's classification".     

Karl Wilmanns (1873-1945)--a biobibliographic view of a psychiatric era

The Heidelberg University school of psychiatry was mainly shaped by the personality of Emil Kraepelin (1876-1926) who won world-wide recognition at the end of the 19th century during the discussions on "dementia praecox". It was his personality that made Heidelberg a fulcrum of a growing new scientific self-assurance that had no precedent in clinical psychiatry which no longer needed the disciplines of neuropathology and neurophysiology as pillars of support to gain recognition among the experts. Although the scientific achievements of Wilmanns cannot be rated as highly as those of E. Kraepelin and K. Jaspers, it is a fact that the period between 1918 and 1933 during which the Department of Psychiatry of the University of Heidelberg as represented by the University Hospital of Psychiatry, was headed by Karl Wilmanns, was the most fruitful period of the "Heidelberg School". 1933 was not only a political but also a psychiatric turning-point. Karl Wilmanns was one of the first of the well-known university teachers who was dismissed from office for political reasons. With his exit the Heidelberg School came to an end, and with it the discipline of psychopathology as a fundamental part of psychiatry- which had been the true progeny of that school. The references outline the influence of biological though on the "zeitgeist" of psychiatry. The contradictions, inhumanity and seduction of this line of thinking were not sufficiently recognised in all their aspects and consequences even by critical minds such as that of K. Wilmanns.