Bleuler and Schizophrenia

¹ Associate Professor, Department of Psychiatry, University of Washington, Harborview Medical Center Campus, 325 Ninth Avenue, Seattle, Washington, 98104, U.S.A.

English-language textbook descriptions of Bleuler's ideas about schizophrenia have muddled the meanings of fundamental accessory, and primary-secondary.

The fundamental-accessory distinction is a descriptive approach attempting to separate symptoms (and signs) peculiar to schizophrenia from those found in other disorders. This distinction is unclear, since (1) there are no criteria described to detect `mild' cases; (2) there is a fuzziness to the use of the terms fundamental-accessory. It is especially puzzling in reference to the distinction between fundamental-association disturbances and accessory speech disturbances; (3) Bleuler's approach to diagnosis ignores this distinction between fundamental and accessory.

The primary-secondary distinction is an approach to aetiology. It assumes being able to distinguish psychic symptoms which are organically determined from those representing normal psychological functions or attempts at adaptation to the primary disturbance. The distinction between organically derived psychic process and non-organically derived psychic process provides an artificial mind-body dichotomy. How is it possible to identify a primary psychic response to an organic insult, especially when different organic insults can lead to identically appearing psychotic pictures? In addition, quite different clinical pictures can arise from a specific brain disease. The search for a primary psychic symptom seems as hopeless as the search for a single aetiology of schizophrenia.

In contrast to these complicated yet ambiguous descriptive and aetiological notions, we have Bleuler's rich ideas about diagnosis and differential diagnosis. This approach, based on years of clinical experience, represents an artistic, intuitive labelling process. Patients are followed for long periods of time and the labels are more akin to determining `family resemblances', rather than diagnosing via necessary and sufficient criteria. The clinical descriptions, the capacity to bring psychoanalytic theory to schizophrenia, are all enduring contributions.

The tension between Bleuler's theory and his practice is felt throughout his book. Over the years the theory has survived with all its encumbrances. The rich clinical descriptions and the wise approach to diagnosis and treatment have been omitted in references to Bleuler. It is time to correct the mistaken impression that Bleuler's major contribution to psychiatry was the `4 A's'.