Paul Eugen Bleuler and the origin of the term schizophrenia (SCHIZOPRENIEGRUPPE)

“All the world's mad except thee and me, and even thee's a little cracked.” – Porter[1] Professor Eugen Bleuler was born in Zollikon in 1857, a small town in Switzerland. Bleuler studied medicine in Zurich , and later pursued his higher studies in Paris, London and Munich. Then Bleuler was conferred doctor of medicine in 1883, and from 1881 to 1883 was an assistant physician in Waldau near Bern. In 1884, Doctor Bleuler travelled to France and England. In the winter term of 1884/1885, Dr. Bleuler worked in the laboratory with Johann Bernhard Aloys von Gudden in Munich. In 1885, Dr. Bleuler became an assistant physician in Burghölzli near Zurich. Then, in 1886, Doctor Bleuler was appointed director of the Rheinau Psychiatric Hospital at the age of 29. Twelve years later Dr. Bleuler was appointed full Professor of psychiatry at the University of Zurich–against the wishes of the Zurich faculty of medicine. Professor Bleuler occupied that chair until 1927.[2–4] The term “schizophrenia” was coined on April 24, 1908, when Professor Bleuler gave a lecture at a meeting of the German Psychiatric Association in Berlin.[1] At that meeting, Professor Bleuler argued that dementia praecox was associated with neither dementia nor precociousness, and emphasized that splitting of psychic functioning is an essential feature of schizophrenia.[2–4] One of the most striking differences between Emil Kraepelin and Bleuler is that Kraepelin collected information about his patients from their records while Bleuler obtained the information by careful clinical observations. He practically lived in the patients’ surroundings. Bleuler derived his concept from the Greek verb schizein, indicating splitting. The second part of the word goes back to the Greek phren, originally denoting ‘diaphragm’ but later changing to ‘soul, spirit, mind’.[5] In this context, ancient Indian views about health deserve a special mention. Hindu descriptions in Atharvana Veda, one of the four Vedas, date back to approximately 1400 BC. Vedas are backbones of Hinduism. In these writings, it has been hypothesized that health is the result of a balance between five elements (Bhuthas) and 3 humurs (Doshas) and that an imbalance between these various elements might result in mental illness. This exemplifies a special reference to mysticism in our postulations of various illnesses especially that are related to mind. Later Bleuler's followers such as Carl Jung took to Eastern Phiosophy in their writings. In 1911, Bleuler wrote “I call dementia precox schizophrenia because, as I hope to show, the splitting of the different psychic functions is one of its most important features. In each case there is a more or less clear splitting of the psychological functions: as the disease becomes distinct, the personality loses its unity”. He recognized that dementia was not a usual characteristic of dementia precox, suggesting the term schizophrenia (splitting of the mind) for the disorder. Bleuler introduced the concept of primary and secondary schizophrenic symptoms; his four primary symptoms (the four As) were abnormal associations, autistic behavior and thinking, abnormal affect and ambivalence. The central symptoms of the illness are the loss of association between thought processes and emotion and behavior. In his view depending on the individual's adaptive capacity and environmental circumstances, this fundamental process could lead to secondary disease manifestations such as hallucinations, delusions, social withdrawal, and diminished drive.[3–5] Professor Bleuler had a special interest in hypnotism, especially in its “introspective” variant. He became interested in Sigmund Freud's Studies on Hysteria. Like Freud, Bleuler believed that complex mental processes could be unconscious. He encouraged his staff to study unconscious and psychotic mental phenomena. Influenced by Bleuler, Carl Jung and Franz Riklin used word association tests to integrate Freud's theory of repression with empirical psychological findings. This short note would not be complete without a small note on the relationship between Eugen Bleuler and Sigmund Freud. Although this relationship has been reported as ambivalent,[6] it appears very clear that Eugen Bleuler always was very cautious about his enthusiasm toward Freudian psychoanalysis. Although he embraced it with open arms and introduced psychoanalysis into his Hospital, he did not agree with the meaning of libido and other concepts. Bleuler also was not enthusiastic about the attachment of sexuality to some of the phenomena and felt it was too premature to accept without scientific proof. Eugen Bleuler always believed that schizophrenia was an organic illness and that it could be inherited. Professor Bleuler used the concepts of psychoanalysis to explain the coloring of symptoms rather than attributing etiological importance. Professor Bleuler's son, Manfred Bleuler, continued his work with respect to familial (hereditary) aspects, early intrafamilial environment and personalities, long-term outcome, and therapeutic interventions. In the summary of this work by Modestin et al. schizophrenic illness remains heterogeneous with regard to illness course and outcome even when narrowly diagnosed with the help of modern operationalized diagnostic criteria. Manfred Bleuler mentioned that the diagnosis was made according to the original concept of Eugen Bleuler and that the illness was considered as a syndrome. They found that the differentiation between schizophrenic and schizoaffective disorders is prognostically valid. One interesting thing was a better agreement of the diagnosis between DSM (diagnostic and statistical manual of mental disorders)-III-R, DSM-III-R, international classification of diseases (ICD) and researh diagnostic crtieria (RDC) whereas there was much less agreement with Bleuler's and Schneider's criteria.[7] In the obituaries of Bleuler, one of his students, Robert Gaupp, wrote “the short, delicately built man with his expressive features was intellectually active to the last”. According to Binswanger, Eugen Bleuler always displayed broad tolerance, though he was not without traces of fanaticism. Eugen Bleuler knew of only two tasks, to which he devoted himself with the entire strength of his unique personality: to be a rational psychiatrist and a genuine human being until his death in 1939. Foot note Although there are some excellent reviews and translations in the German language about the history of schizophrenia and Eugen Bleuler's life, due to the space constraints, only a few of the important references have been cited.[8]

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