'Dementia Praecox or The Group of Schizophrenias' by Eugen Bleuler (1911)

A selection from Dementia Praecox oder die Gruppe der Schizophrenien (Dementia Praecox or the Group of Schizophrenias) by Eugen Bleuler, 1911.

Burghölzli psychiatric hospital of the University of Zurich.

In 1898, Bleuler became the director of Burghölzli psychiatric hospital in Zurich, where he remained for nearly 30 years. Carl Jung did his medical training their where he served as Bleuler's assistant. In a review he wrote in 1904, Bleuler said
In his studies on hysteria and dreams, Freud has shown a part of a new world, and that is not all. Our consciousness sees only the puppets in its theatre; in the Freudian world, many of the strings which move the characters are shown.

[Work in Progress]

Translator's Preface

[Zilboorg] said of Bleuler's monography that, "it was the classic work of twentieth century psychiatry." I trust he will be pleased that it was this commend in his History of Medical Psychology [1941, see my selection] which made me feel that it was more than a worthwhile effort to undertake this translation.

Author's Preface

Our knowledge of the disease group which Kraepelin established under the name of Dementia Praecox is to recent to warrant a complete description. The whole complex is still too fluid, incomplete, tentative.
The whole idea of dementia praecox originates with Kraepelin. Almost exclusively to his work we also owe the grouping and description of the separate symptoms.

General Introduction

Kraepelin finally succeeded in isolating a number of symptoms which were present in maladies with very poor prognoses while absent in other disease-groups. The psychoses characterized by the presence of these symptoms were subsumed under the term Dementia Praecox.

...several astute minds, even before [Kahlbaum], had already known that the old names, such as melancholia, insanity, mania, deliria, merely designated symptom-pictures. However, one was unable to isolate true disease processes; therefore symptomatological entities were treated as if they corresponded to real diseases.

Section I Symptomatology

Chapter I The Fundamental Symptoms

The fundamental symptoms consist of disturbances of association and affectivity, the prediliction for fantasy as against reality, and the inclination to divorce oneself from reality (autism).

A. The Simple Functions

1. The Altered Simple Functions

(a) Association

In this malady the associations lose their continuity. Of the thousands of associative threads which guide our thinking, this disease seems to interrupt, quite haphazardly, sometimes such single threads, somtimes a whole group, and sometimes even large segments of them. In this way, thinking becomes illogical and often bizarre. [...] A high degree of associational disturbances usually results in states of confusion.

...schizophrenic association disturbances.

...thoughts are subordinated to some sort of general idea, but they are not related and directed by any unifying concept of purpose or goal. It looks as though ideas of a certain category.... were thrown into one pot, mixed, and subsequently picked out at random, and linked with each other by mere grammatical form or other auxiliary images.

In analyzing the disturbances of association, we must realize the influences which actually guide our thinking. [...] Only the goal-directed concept can weld the links of the associative chain into logical thought. However, what we mean by a goal-directed concept is not just one single idea, but an infinitely complicated hierarchy of ideas. If we work out a particular theme, the first goal is to give permanent formulation to a part-idea for which, usually, a sentence will serve as a symbol. A further, more generalized goal is the construction of a paragraph which again will be subordinated to a chapter and so forth.

Frequently the patient drops a thought in an entirely matter-of-course way, only to proceed to quite a different one that has no recognizable associative connection with the previous one.

This has been termed "dissociated thinking" (Ziehen, 842) or "incoherence"; the external disease picture can be labeled "confusion."

Different ideas that do not belong together are combined.

The emergence of an idea without any connection with a previous train of thought, or without any external stimulus, is so foreign to normal psychology that one is obliged to look even in the patient's seemingly most far-fetched ideas, for the associative path... .  In this way, it may be possible in some, though not in all cases, to demonstrate the connecting links. Still, in a sufficient number of cases, we will succeed in pointing out several of the main directions along which the derailment of thoughts took place.

...they are for the most part the very same directives which determine the emergence of new connections after the total break in thought: connections with accidentally aroused ideas, condensations, clang-associations, intermediate associations, and persevation of ideas (stereotypy). All these thought-connections are not foreign to the normal psyche either. But they occur only exceptionaly and incidentally, whereas in schizophrenia they are exaggerated to the point of caricature and often actually dominate the thought-processes.

...the clang associations very often has the schizophrenic mark of the bizarre.

It may be due to purposelessness and stereotypy of ideas, that the patient is really unable to pursue a thought to its conclusion; a senseless compulsion to associate may replace thinking proper.

In this manner patients get entangled in long enumerations which clearly betray the schizophrenic character of their associative disturbances.

Common to all is the fastening upon a sense impression because of the lack of a goal-concept.

The schizophrenic's "distractability" (or what Ziehen termed, "vigility of attention:) is not necessarily altered in any specific direction as far as the associations are concerned. Here we are dealing with... the patients active exclusion of the outside world. At times, the patients appear to be completely dependent upon and at the mercy of external impressions, and not to be in possession of their own directives and aims... . At other times the patients are in no way distractible. The most powerful stimuli are incapable of influencing their train of thought or of arousing their attention.

Even a change of circumstances will hardly influence these patients, as long as they are in a passion.

....peculiarities of schizophrenic thinking...

The Course of the Associations

Naturally, we have in intercurrent manic conditions an "accelerated" flow in the sense of a flight of ideas and in depressive conditions, a slowing-down. ...schizophrenic brain-processes

Many patients complain that they must think too much, that their ideas chase each other in their heads. They themselves speak of "thought-overflow" (because they cannot hold anything in their minds), of "pressure of thoughts," of "collecting of thoughts," because too much seems to come to mind at one time. [...] ....it is certain that in many a patient there is a pathological pressure of ideas. The patients then have the feeling of being compelled to think. Often enough, they will say that someone is making them think in this fashion.

We owe one of the best descriptions of this phenomenon to an intelligent patient of Forel's (229). [...]

In my mind there ran like an endless clockwork a compulsive, torturing, uninterrupted chain of ideas. Naturally, they were not too sharply defined or clearly developed. There were joined idea upon idea in the most remarkable and bizarre series of associations although there was always a certain definite or inherent connection from link to link k. There was sufficient coherence or system to the whole so that I could always differentiate the light and shadowy side of things, people, actions, or spoken words which struck my interest. What ideas, what images have not umbled around in my head! What amusing associations of ideas have cropped up! I always seemed to come back again and again to certain conceptions, to certain images which, now, however, I can hardly remember... . They did seem to constitute steps in that racing train of thoughts; and I would speak out loud rapidly... the idea which my restless thoughts had just reached. I also used this means in order not to lose the threads and to maintain a certain control over the overwhelming, maddening, rushing train of thoughts.

...all of a sudden, in the middle of a sentence or in passing to a new idea, the patient stops and cannot continue any further. Often he is able to overcome the obstacle by repeating the attempt. Another time, he succeeds only in thinking in a new direction. Frequently, the blocking cannot be overcome for quite a long interval; in such cases it can spread over the entire psyche, the patient remaining silent and motionless and also more or less without thoughts.

The "blocking" is not absolute and invincible in each case. By persistent questioning, by using various stimuli and especially by distraction, one can often break through or circumvent it. The patients, however, have an unpleasant feeling about such manoeuvres.

(b) Affectivity

In the outspoken forms of schizophrenia, the "emotional deterioration" stands in the forefront of the clinical picture. [...] They sit about the institutions to which they are confined with expressionless faces, hunched-up, the image of indifference.

At the beginning of the disease, we often see an over-sensitivity, so that the patients consciously and deliberately isolate themselves in order to avoid everything that may arouse affects, even though they may still have some interest in life. Latent schizophrenics may appear almost too labile in their affect, almost sanguine. But there is a lack of depth to the affect. [...] ...there are many schizophrenics who display lively affect at least in certain directions. Among them are the active writers, the world improvers, the health fanatics, the founders of new religions. These people are one-sided in their thinking and inconsiderate in their behavior.

2. The Intact Simple Functions

(d) Consciousness

...the psyche creates from within an entirely personal world which is then projected outwards. We speak then of "Dammerzustande" (twilight states).

B. The Compound Functions

(a) Relation to Reality: Autism

The most severe schizophrenics, who have no more contact with the outside world, live in a world of their own. They have encased themselves with their desires and wishes (which they consider fulfilled) or occupy themselves with the trials and tribulations of their persecutory ideas; they have cut themselves off as much as possible from any contact with the external world.
This detachment from reality, together with the relative and absolute predominance of the inner life, we term autism. [authors note: Autism nearly coincides with what Freud has termed auto-eroticism. [...] In essence the term, autism, designates in a positive way the same concept that P. Janet formulated negatively as "the loss of the sense of reality."]

...the indifference of patients toward what would be considered their nearest and dearest interest becomes understandable. Other things are of far greater importance to them. They do not react any more to influences from the outside. They appear "stuporous"... . The external world must often appear to them as rather hostile since it tends to disturb them in their fantasies. [...] ...in the beginning of their illness, these patients quite consciously shun any contact with reality because their affects are so powerful that they must avoid everything which might arouse their emotions. The apathy toward the outer world is then a secondary one springing from a hypertrophied sensitivity. 
Austism is also manifested by many patients externally. (Naturally, this is, as a rule, unintentional.) Not only do they not concern themselves with anything around them, but they sit around with faces constantly averted, looking at a blank wall; or they shut off their sensory portals by drawing a skirt or bed clothes over their heads. 

The autistic world has as much reality for the patient as the true one, but his is a different kind of reality. Frequently, they cannot keep the two kinds of reality separated from each other even though they can make the distinction in principle.

The reality of the autistic world may also seem more valid than that of reality itself; the patients then hold their fantasy world for the real, reality for an illusion. [...] The patient may be very aware that other people judge the environment differently. He also knows that he himself sees it in that form but it is not real to him. [...] To a considerable extent, reality is transformed through illusions and largely replaced by hallucinations (twilight states, Dammerzustande).
In the usual hallucinatory conditions, more validity is, as a rule, ascribed to the illusions; yet the patients continue to act and orient themselves in accordance with reality. ...the autism itself may reach such a high degree of intensity, that the patients' actions lose all relation to the blocked-off reality. The sick person deals with the real world as little as the normal person deals with his dreams. Frequently both disturbances, the stuporous immobility and the exclusion of reality, occur simulataneously.

A complete and constant exclusion of the external world appears, if at all, only in the most severe degree of stupor. In milder cases the real and the autistic worlds exist not only side by side, but often become entangled with one another in the most illogical manner.

Wishes and fears constitute the contents of autistic thinking. In those rare cases where the contradictions to reality are not felt at all, it ist he wishes alone which are involved; fears appear when the patient senses the obstacles to the fulfillment of his wishes. Even where no true delusions arise autism is demostrable in the patients' inability to cope with reality, in their inappropriate reactions to outside influences (irritability), and in their lack of resistances to every and any idea and urge.
In the same way as autistic feeling is detached from reality, autistic thinking obeys its own special laws.

Often the patients depart more and more from the norm in their behavior and become progressively more "whimsical." [...] The tendency to buffoonery can also become so overhwelming as to lead to the external picture of monotonous, chronic "clowning."

Intercourse with other people is not disturbed merely by the schizophrenics' irritability and their peculiarities. In their austism they can comport themselves in a crowded work-room as if they were along; everything which concerns the others does not exist for them. [...] They have turned their backs on the world, and seek to protect themselves from all influences coming from the outside. This may develop into a sort of stereotypy in whcih the patients feel comfortable only in some corner where they can hug the walls.

...when autism gets the upper hand, it creates a complete isolation around the sick psyche. The most severe schizophrenics live in their own rooms as if in a dream... .

Chapter II The Accessory Symptoms

(a) Hallucinations, Delusions, and Illusions

In hospitalized schizophrenics it is mainly the delusions and particularly the hallucinations which stand in the forefront of the picture. The complaints of the patients, the peculiarities of their behavior, agitation and seclusion, ecstacies, despairs, and outbreaks of anger- all these phenomena are usually related to, if not direct consequences of, the delusions and hallucinations.

Almost every schizophrenic who is hospitalized hears "voices," occassionally or continuously.

The confined patient hears voices that promise him impending freedom, and others describing his "imprisonment" as eternal.

For the patient as for his attendant the "voices" become, above all, the representatives of the pathological or hostile powers.

Threats and curses form the main and most common content of these "voices."

The voices are very often contradictory. At one time, they may be against the patient (when hs is thinking of God, they deny His existence); then they may contradict themselves. [...] The roles of pro and con are often taken over by voices of different people. [...] Besides their persecutors, the patients often hear the voice of some protector. [...] The voices command him to go bathing and then jeer at him for obeying. The attendants, the doctors, policemen, "the voices," in general, like to criticize his thoughts, behavior and actions. While getting ready in the morning a patient hears, "Now she is combing her hair," "Now she is getting dressd;" sometimes in a nagging tone, sometimes scornfully, sometimes with critical comments.
Also, the voice may forbid the patient to do what he was just thinking or doing. At times, the hallucinatory voices represent sound criticism of his delusional thoughts and pathological drives. For this type of voices, the patients find special terms, such as "voices of conscience," or "nagging devil," to indicate the negative aspect.

Sometimes the voices merely state what the patient does and thinkgs, clearly analogous to the symptom called "naming."

Magnan found that, when good or bad voices are differently localized, the "good" voices come from above, the "bad" ones from below. This constellation is not at all rare and corresponds to our religious concepts. [..] The same significance can be attached to what a patient tells us: that on eht quiet wards he hears the voices as from above; while on the disturbed wards he hears the voices coming from below. He particularly fears the voices coming from below.

...bodily sensations unknown to the normal person appear in great numbers. When someone is nice to one of our paranoids, then he feels "touched delicately." If someone is mean to him, "he is struck a blow." He feels it not on his skin, but rather more in his head; it then spreads through the entire body, changing the patient's posture.

Outside of acute twilight states, whole scenes are rarely hallucinated. But in such states they are quite common... . [...] Above the woman-doctor's head a group of people are standing; in the front row are the good ones, in the back row the evil ones, among them her parents (whom the patient fears for good reasons). The heavens stand open; the angels and the saints and God Himself communicate with the patient. The appearance of frightful figures from Hell are very common. Robbers threaten the patient. Words in all sorts of lettering occur quite often, even whole sentences. Sometimes the writing appears very suddenly, as the embodiment of any odd notion. Thus a paranoid suddenly saw the word, "poison" in the air at the very moment when the attendant made thim take his medicine. Also, perfectly conscious thoughts or the very sermon that is being listened to can be seen written in various letters and signs: "Thoughts-becoming-visible." (Halbey)

One can hope to move oneself properly in one's environment only if the latter is comprehended visually to a certain extent. A completely delirious patient who hallucinates away his entire surroundings and substitutes his own imaginings for the real is relatively rare in schizophrenia. In the long run a patient who is still capable of acting cannot maintain visual hallucinations, but only illusions, and of these only those which can come to some compromise with reality. The patient by means of his illusions may see palaces or prisons instead of a hospital ward.

The doctor appears as devils.

Frequently, there is simply a feeling of "strangeness." Everything seems to be different from what it used to be for the patient. 

As in other diseases, so too in schizophrenia, the hallucinations are most likely to occur when the patients are left to themselves. Distraction reduces them, the loneliness and quiet of the cell favours them. Darkness multiplies the visions... . 

The patients believe in their interpretations which they take for perceptions.

The situation with regard to projection is most remarable. Many hallucinations are projected outward exactly as are real perceptions and cannot be differentiated subjectively from them. The hallucinations of organ sensations apparently occupy a very special position. For these hallucinations, the body becomes what one otherwise considers the external world.

An intelligent hebephrenic, while we were talking to him, suddenly saw the devil standing behind him; and it was so clear and vivid that he could draw it for us. He declared, in response to our objections, that he just had the gift of seeing through the back of his head what was behind him.

For the most part, the reality value of hallucinations is as great as that of real perceptions, or even greater. Whenever reality and hallucinations conflict, it is usually the latter which are considered as real. If one doubts the reality of the patient's hallucinations, we usually get the following retort: "If that is not a real voice then I can just as well say that even you are not now really talking to me."

They "do not have voices, only thoughts which other people do not have"; or "instead of thoughts, they have voices; all their thoughts suddenly become voices."

(b) Delusions

The persecutory delusion is the most frequently met of all the well known types of delusional content.

Section III

The Course of the Disease

B. The Onset of the Disease

...there are early character anomalies which can be demonstrated by careful case histories in more than half the individuals who later become schizophrenia: the tendency to seclusion, withdrawal, together with moderate or severe degrees of irritability. THey already stood out as children because they were unable to play with others and followed their own ways instead. [...] The peculiar intellectual characteristics often induce the comrades of these candidates for schizophrenia to regard them as "crazy" at a rather early stage. All ten of my own school comrades who later became schizophrenics, were quite different from the other boys.

"By means of case histories it is very interesting to follow the genesis of the symptoms which intitially are rather mild and inconspicuous but gradually take on increasingly odd, bizzare, and psychotic qualities, transforming the patient's behavior until it is ever more rigid, stubborn, and negativistic."

Before the actual onset of the disease, the patients frequently complain about disturbing dreams which keep haunting them during their waking hours.

C. The Termination of the Disease

2. Degree of Deterioration and Possibilities of Cure.

...cure demands a restitutio ad integrum be demonstrated.

An individual who can again support himself outside an institution can be considered cured in a certain sense. [...] From a scientific standpoint, one cannot call them cured since a clear concept of cure demands a restitutio ad integrum or at least the status quo ante.

...the degree of sensitivity of the patient's relatives will often determine whether he is cured or not. Such a conception of cure cannot be applied in pathology. 

The episode which led to the patients' admission to the hospital is rarely the real beginning of the disease which had already begun to develop furtively a long time before; but the first indications were mistaken for character peculiarities. [...] It is often impossible to take as point of comparison the individual's condition before the onset of the disease because schizophrenia begins surreptitiously at the time of the most rapid psychic transformation or even in early childhood. Once again we are confronted with that difficult question: "What is a peculiarity of character and what is a schizophrenic symptom?"

Good mental health cannot be directly diagnosed; we assume it when we find no signs of disease inspite of thorough examination.

I cannot understand how Strohmayer ever arrived at the erroneous conclusion that affective deterioration is usually detected by ordinary lay people. 

An often discussed criterion of cure is that of the patients' insight into the nature of their illness. People who speak of their delusions and their weired behavior during the attack as being pathological phenomena, who understand that they had to be handled the way they were, and are even grateful to the doctor or hospital- these people are not without reason easily considered as cured; whereas the opposite is thought of as being a rather certain sign of continuing disease. [...] Even true insight may be distinctly pathological, because one gets the impression that only one part of the patient's psyche understands what is going on. ...the connection between their pathological experiences and their present ego is lacking. This situation can become particularly clear when one is able to contrast such cases with, for example, a recovered melancholic patient. In the latter instance we have a free discussion and description with reproduction of the feelings and emotions of those moments of their illness; in schizophrenics, on the other hand, we get a labored, strained presentation of events and experiences which are termed delusional with a few scanty words or phrases and accompanied by an affect which hardly corresponds to the situation of a human being saved from a delusional world.

Therefore, we do not speak of cure but of far-reaching improvements and differentiate them from the severe deteriorations.

As a criterion of the severity of the deterioration, I take the individual's capacity for carrying on his vocation, or his ability to support himself outside a hospital.

D. The End States of the Disease

The majority of the terminal conditions escape our observation. The individuals live outside the hospital; they are often considered as healthy, although perhaps as rather peevish, stubborn, whimsical, sad or stupid, etc. Many of these people have merely lowered the level of aspirations with regard to their accomplishments and claims on the world.

The most extensive form is that of the dull, apathetic deterioration (or dementia).  [...] "...the dull, indifferent willessness... give the large mental institutions of the custodial type their particular stamp."

Section IX 

The Causes of the Disease

Whether there exists an individual disposition to this disease is qusetionable. Undoubtedly, many of the later schizophrenics were peculiar, withdrawn, and autistic already in youth. But at this time, we cannot decide whether such behavior is the expression of a disposition to the disease or the surreptitious beginnings of the disease itself.

...masturbation was mentioned as one of the most common causes of "juvenile psychoses." [...] Above all, it is autism which compels the patient to satisfy himself on himself. It is only in the sexual sphere that it is still possible for him to fulfill autistically some of his desires. To the patient, the imaginary mistress is more than a real one. For this reason normal sexual intercourse is sought so little [authors note: It seems that fewer schizophrenics suffer from venereal disease than mentally healthy individuals. This fact is particularly noteworthy in view of the schizophrenic's lack of inhibition and his general indifference.] Therefore the sexual life of even those patients who are not very far advanced in their illness centers almost completely about masturbatory satisfaction.

Section X

The Theory

Chapter II

The Theory of the Disease

...it is not absolutely necessary to assume the presence of a physical disease process. It is conceivable that the entire symptomatology may be psychically determined and that it may develop on the basis of slight quantitative deviations from the normal.

Thus, there has been no lack of attempts to explain this disease on a functional basis.