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«Primary», «basic» and «secondary» symptoms of schizophrenia in the concept of E. Bleuler
Abstract
Two first works of swiss psychiatrist E. Bleuler that revise the symptomatology of Kraepelinian dementia praecox leaning on some findings of the psychoanalysis of S. Freud, C. Jung, F. Riklin, K. Abraham and on the P. Janet’s concept of psychasthenia are analyzed. The early concept of primary (testifying the direct organic lesion) and secondary (of psychogenic origin) symptoms of schizophrenia formulated by E. Bleuler is compared with his following concept of «basic» and «accessory» symptoms of schizophrenia. The concept of primary and secondary symptoms of schizophrenia was created firstly as a ground for the prognosis of the disease, and the concept of basic and accessory symptoms for the confident diagnosis of the disease. E. Bleuler’s concept accentuated the diagnosis of schizophrenia on the psychopathological and pathopsychological state of the patient, in contrast to E. Kraepelin’s concept of dementia praecox based on the course and outcome, made possible the expansion of schizophrenia boundaries at the expense of different psychotic and nonpsychotic disorders that other authors attributed to the forms of «degenerative madness», neuroses and psychopathies.
Negative symptoms of schizophrenia represent, at the present stage of their study, a certain group of mental pathology. They include motivation disorders or volitional disorders (anhedonia, abulia, asociality) and disorders of reduced expression or emotional disorders (alogia/poverty of speech and emotional decline/flattening). Negative symptoms are key disorders in schizophrenia, often appear at the pre-manifest stage of the disease, and significantly affect the prognosis and response to therapy. From a scientific and practical point of view, it is important to distinguish between primary and secondary negative symptoms, where the primary symptoms are nuclear, inherent in schizophrenia, and the secondary ones are the result of the influence of positive symptoms (delusions, hallucinations), depression, side-effects of medications, social isolation and hospitalism. Changes in the concept of primary and secondary negative disorders as well as a pathophysiological basis of negative symptoms are considered.
The article argues for the discrepancy between the artificial construction of «schizoaffective disorder» (SAD) and the principles of nosological diagnostics. The term of «acute schizoaffective psychoses», was introduced by Y. Kazanin in 1933, is still remain a controversial nosological unit. This diagnosis often made at the cut of a psychotic episode on a «dichotomous scale» by «weighing» schizophrenic and affective symptoms. In the history of the creation of the concept of SAD, there is a tendency towards reductionism and the search for universal manifestations. Each individual clinical case must be considered holistically. It is unacceptable to extract the individual signs (which does not fit syndromal structures) from general picture of the disease. However, this requirement is in contradiction with the current trends towards simplification, discreteness and loss of clinical thinking in currents classifications of diseases. The inadequacy of the available diagnostic approaches and criteria for distinguishing between SAD, bipolar disorder and schizophrenia leads to the fact that the patient’s diagnosis is based on the subjective preferences of a clinician, and during patient’s life can many times be changed. The results of the the phenotype and genotype of the corresponding disorders searching partially shed light on the features of the diagnosis; but at the same time, some researchers are artificially combine the discrete properties and coming to incorrect conclusions; often such an identity simply does not make sense. The authors join opinion of experts who suggesting the existence of a «third psychosis» or even several discrete forms of diseases, which, along with unrecognized attacks of bipolar psychosis and schizophrenia are still mistakenly dissolved in the dichotomous / dimensional hybrid SAD. Diagnostics, taking into account the follow-up, regularities of the course, pathophysiological changes and psychopathological structure, has not only clinical value, but is also responsible for the selection of effective treatment, correct preventive measures, affects the social status and, ultimately, the quality of life of the patient.
Madness is a significant public health problem. What is the concept of madness? What are the characteristics of imperial and rulers' madness, what are the cultural phenomenon, creativity and psychopathology? How can writers, musicians, dancers, and painters be characterized? What are the types of madness?
Biblical verses related to madness were analyzed from a contemporary perspective.
The dynamics of the concept of the continual development of mental disease from the constitution that was the most clearly formulated by a Russian psychiatrist Th. Tiling in the discussion with the German psychiatrist C. Neisser is presented. The concept of Th. Tiling influenced E. Bleuler's approach to the description of basic and accessory symptoms of schizophrenia and also on E. Kretschmer's concept of constitution and mental disease. Main characteristics of cycloid and schizoid personality of E. Kretschmer's concept are presented. The author notes the very broad E. Kretschmer's understanding of 'psychesthetic proportion', which state explains not only the diversity of schizoid types but also many psychotic psychopathological phenomena. In addition to the altered affectivity, autism was the second basic symptom of schizophrenia, which mild manifestations form the basis for E. Kretschmer systematics of schizoid types. E. Kretschmer's understanding of autism was broader than Bleuler's and was presented by E. Kretschmer as a symptom derived from special schizoid affectivity (psychesthetic proportion). The critics of E. Kretschmer's concept by some contemporary German psychiatrists is also considered.
The understanding of psychopathic personalities in early works of Kurt Schneider making start from the traditional doctrine of temperament but straying from the degeneration theory and constitutional concepts of E. Kretschmer is analyzed. Under the notion of psychopathic personality K. Schneider means properly the variation of the character that according to his famous definition can cause by its 'deviations from the average' suffering for the society and can also suffers itself due to those deviations. The importance that K. Schneider attached to the differentiation of all personality anomalies from schizophrenic process is emphasized. The basic characteristics of 10 special types of psychopathic personalities according to K. Schneider's systematics are also analyzed. K. Schneider pursued the identification of one prominent psychological trait in the building of his systematics and definition of special psychopathic types. He strived to avoid sociological labels that had been used by his predecessors ('liars and cheaters', 'enemies of society' 'inborn prostitute' and so on). The great influence of E. Kretschmer on K. Schneider's characteristics of 'affective' and 'unsure of himself' psychopaths is noted although K. Schneider did not accepted the constitutional systems of E. Kretschmer and did not highlight 'schizoid' psychopathy. The growth of psychopathic personality groups compared with the last lifetime systematics of E. Kraepelin (from eight to ten) appears by K. Schneider only formal because E. Kraepelin placed some clinically detailed descriptions of personality disorders beyond the main heading.
On the 100th anniversary of the publication of Eugen Bleuler's Dementia Praecox or the Group of Schizophrenias, his teachings on schizophrenia from that seminal book are reviewed and reassessed, and implications for the current revision
of the category of schizophrenia, with its emphasis on psychotic symptoms, drawn. Bleuler's methods are contrasted with Kraepelin's,
and 4 myths about his concept of schizophrenia addressed. We demonstrate that (1) Bleuler's concept of schizophrenia has close
ties to historical and contemporary concepts of dissociation and as such the public interpretation of schizophrenia as split personality has some historical basis; (2) Bleuler's concept of loosening of associations does not refer narrowly to a disorder of thought but broadly to a core organically based psychological deficit which underlies
the other symptoms of schizophrenia; (3) the “4 A's,” for association, affect, ambivalence, and autism, do not adequately summarize Bleuler's teachings on schizophrenia and marginalize the central role of splitting in his conception; and (4) Bleuler's ideas were more powerfully influenced by Pierre Janet, particularly with regard to his
diagnostic category Psychasthenia, than by Sigmund Freud. We conclude that Bleuler's ideas on schizophrenia warrant reexamination in the light of current criticism
of the emphasis on psychotic symptoms in the schizophrenia diagnosis and argue for the recognition of the dissociative roots
of this most important psychiatric category.
18 Lange Zeit ist wenig beachtet worden, daß die Eltern aktive Partner in der Auseinandersetzung mit den Kindern sind und daß diese Auseinandersetzungen auch auf sie Rückwirkungen haben. Ihre Emotionen gehen bei der Entwicklung des Kindes und seinen Beziehungen zu ihnen selbst stärker mit, als sie es vor dem eigenen Bewußtsein wahr haben wollen. Dabei werden ihre eigenen Kind heitskonflikte wieder lebendig. Schwerwiegend wirkt sich das z. B. oft bei einer jungen Mutter aus, die in ihrer eigenen Kindheit die mütterliche Liebe und Fürsorge entbehren mußte: sie kann dann manchmal die richtige Mütterlichkeit nicht entwickeln, sie bleibt ihr fremd, weil sie ihr nicht vorgelebt wurde; sie hat unklar das Gefühl der Überforderung, da sie so viel schenken sollte, wovon sie nichts erhalten hat. Depressionen im Wochenbett und falsche Einstellungen zum Kind, in denen versucht wird, mangelnde Mutterliebe durch Übergewissenhaftig keit in der körperlichen Pflege zu ersetzen, können die Folge sein. Im Alter wird das Problem der Anpassung an die veränderten Kräfte allgegen wärtig. Der Versuch, sich in derselben Art durchzusetzen, wie es Jüngeren beschieden ist, muß zu Enttäuschungen und Bitterkeit führen. Wenn es hingegen gelingt, die erst in späteren Jahren erworbenen Fähigkeiten, die einem Jüngeren nicht zukommen, auszunutzen, hilft dies wesentlich zum inneren Gleichgewicht. Der Greis reibt sich auf, wenn er in jeder Hinsicht "mit seiner Zeit leben" und alle Neuerungen mitmachen soll.
The author analyzes the features of the syndrome of «delusional fantasies» (delusion-like fantasies) in the concept of K. Birnbaum. According to this concept, psychopathic constitutions, due to the presence in the structure of dissociation, are the basis for the development of delusions per se. «Dreamer» and «vershroben» types are predisposed to the syndrome of «delusional fantasies». It is emphasized that initially the syndrome of «delusional fantasies» was described as a peculiar phasic episode of delusions in psychopaths, aged between 20-30 years. In the current domestic literature, delusion-like fantasies are regarded as non-delusional bizarre fantastic ideas in children and adolescent patients.
The author analyzed a symptom concept of Th. Ziehen that had competed with the Kraepelin nosological concept of mental disorders. The classification of psychopathological constitutions and defective states in mental diseases used by Th. Ziehen is discussed. The particular significance given by Th. Ziehen to overvalues in the formation of psychopathological phenomena and sexual perversions as major characteristics of the general type of inherited psychopathic constitution is emphasized. The Th. Ziehen’s definition of psychopathic constitution is compared to Kraepelin’s conception of psychopathic personality.
The author analyze conceptions of mental signs of predisposition (diathesis, vulnerability) to non-psychotic and delusional mental disorders of functional origin described in the works of leading French psychiatrists of the late 19th/early 20th centuries (E. Regis, P. Serieux, J. Capgras, E. Dupre, J. Levy-Valensi etc). The descriptions of characteristics of some constitutional types and the differences in the structure of constitutional types and the structure of delusional disorders developed on their basis are compared.
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