Descriptive Psychopathology: The Signs and Symptoms of ...

37 Chapter 2: A history of psychiatric classificationinterplay of the finer feelings”, poor modulation of mood, rigidity of affect,parathymias and loss of emotional rapport).3 Ambivalence (synchronous laughing and crying, expressions of love and hatefor the same person, catatonic indecision and ambitendency).Psychiatrists in the USA during the 1950s and 1960s separated dereistic thinkingas a primary symptom, changed it to “autistic thinking” and offered themnemonic for schizophrenia of “Bleuler’s Four As”: associational loosening,autism, affective flattening, and ambivalence. By the late 1960s, these easilyover-interpreted notions resulted in almost all psychotic patients in the USAbeing seen as schizophrenic.Bleuler’s broad and easily misapplied primary features of dementia praecoxguaranteed clinical heterogeneity. His patients developed illness throughout adultlife and not just in late adolescence. Many did not progress to dementia.He offered the term schizophrenia to replace dementia praecox, highlightingwhat he considered the more specific splitting of psychological functions thathe found in his patients.Thus, the present-day formulation that there are two “big” psychotic disorders,schizophrenia and manic-depressive illness was established over 100 years ago.However, while manic-depression was recognized for millennia, schizophreniawas relatively new to classification. Like a house of cards, Bleuler acceptedKraepelin’s basic incorrect construct of the tripartite mind while Kraepelin builthis ideas upon Kahlbaum’s distinct but invalid disease notion of catatonia. Bleulergreatly influenced psychiatry in the USA, while Kraepelin’s influence remainedmostly European.Early-twentieth-century skepticsEarly-twentieth-century psychiatrists were reluctant to accept Kraepelin’s formulations.92 The notion of a unitary psychosis still prevailed in German-speakingcountries. Alfred Hoche compared the new formulations to an “attempt to clarifya turbid liquid by pouring it from one receptacle to another”. 93 Many psychiatristswere alarmed by the lack of validating support for the dementia praecoxconstruct and the broadening of the traditional vision of manic-depression.The phenomenologist, Karl Jaspers wrote:No real disease entity has been discovered by this method of approach. We have no scientificknowledge of any disease which satisfies the claims made for a disease-entity ... the twodisease-groupings of manic-depressive psychosis and dementia praecox are almost completelyunknown so far as their causes and cerebral pathology are concerned. Their definition dependsrather on the basic psychological form or on the course run (towards recovery or not) withvarying emphasis placed on the one or the other. Whereas one set of investigators [Bleuler]pushes the initial outbreak into the foreground and thus makes the dementia praecox group