Descriptive Psychopathology: The Signs and Symptoms of ...

36 Section 1: Present, past, and futureHebephrenia, with its early onset and dementing picture, became the model forthe longitudinal pattern of dementia praecox. But validity of dementia praecoxrested on the validity of catatonia and hebephrenia and the value in linking themas a single disease with a deteriorating course. Present-day classifications followKraepelin’s error.Kraepelin added Kahlbaum’s dementia paranoides with its onset later in life tothe dementia praecox grouping, further complicating the construct of an early onsetdisease affecting emotion, intellect, and will that progressively worsened to dementia.He also recognized that some patients with dementia praecox recovered. 89While separating manic-depression from dementia praecox, Kraepelinexpanded the construct by adding Kahlbaum’s dysthymia group (melancholiaand mania) and the Falret/Baillarger circular insanity with their later illnessonsets, recurring episodes, and more optimistic outcomes. 90By the end of his career, Kraepelin had lumped most of the dementiasoccurring before age 50 and all of the various forms of mania, melancholia andcircular mood disorders into two “functional” psychoses, dementia praecox andmanic-depressive insanity, respectively. This formulation has become the bedrockof the ICD and DSM. Its weak logic (all conditions with the same longitudinalcourse have similar etiology), and faulty construct (the effect of the illness on thetripartite mind determining grouping) still adversely affects present-day efforts todelineate psychiatric illness.The splitters and lumpers in confusionEugen Bleuler combined observation with theory, roiling Kraepelin’s more clearlystated but poorly formulated classification. Bleuler accepted Kraepelin’s ideathat dementia praecox affected the three areas of the mind, but theorized thatthese fundamental or primary deficits resulted in psychological processes thatelicited the accessory or secondary features of illusions, hallucinations, anddelusions. Influenced by Jungian theory, Bleuler envisioned the fundamentalsymptoms to be found in all patients with schizophrenia while accessory symptomswere less universal and more fluctuating. But while Kraepelin envisionedone disease, Bleuler recognized sufficient clinical variability to warrant the idea ofseveral disorders, one of which represented the majority of such patients. 91Bleuler’s (1976, pp. 372–87) primary symptoms for schizophrenia were:1 Disturbances in associations (with examples that correspond to rambling speechor word salad, answers that do not explain, portmanteau words, derailment,dereistic [“loss of contact with reality”] thinking, “obstruction” or deprivationof thought).2 Loss of normal affectivity (from indifference to one’s surroundings, family andfriends to temporary reduction of emotionality or “contraindication in the