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Interpretation of Schizophrenia

Second Edition

Silvano Arieti, M.D.

Copyright © 1974 Silvano Arieti.

e-Book 2015 International Psychotherapy Institute

All Rights Reserved

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 Table of Contents
Preface

Acknowledgments

1 The Basic Questions

2 Historical Review of the Concept of Schizophrenia

3 The Manifest Symptomatology

I General Remarks

II General Description of the Disorder

III Taxonomy of Schizophrenia

IV The Paranoid Type

V The Hebephrenic Type

VI The Catatonic Type

VII The Simple Type

VIII Ill-Defined or Controversial Types

IX Atypical Forms of Schizophrenia

X Changing Aspects of Schizophrenia

 XI The Course of Schizophrenia

4 The Diagnosis and Prognosis of Schizophrenia

I Diagnosis

II Prognosis

5 First Period: Early Childhood and Family Environment

I Introductory Remarks

II The First Few Months of Life

III The Family Environment

IV Conclusions about the Family of the Schizophrenic

V Early Development

VI Psychodynamic Development in the Early Childhood of Schizophrenics

VII The Building of Early Defenses

6 Second Period: Late Childhood

I The Abnormal Dialogue

II The Emerging Personality

III The Schizoid Personality

IV The Stormy Personality

 V Later Developments

7 Third Period: Adolescence and Early Adulthood

I Further Aspects of the Prepsychotic Personality

II The Injury to the Self

III PSYCHOSEXUAL CONFLICTS

IV The Prepsychotic Panic

8 Fourth Period: The Psychosis

I The Onset

II Different Views of the Psychodynamic Meaning of the Psychosis

III Relevance of Late Precipitating Events

9 Patients Studied through Family Members

10 Study of Catatonic Patients

11 Study of Paranoid Patients

12 Study of Hebephrenic Patients

13 Postpartum Schizophrenic Psychoses

I General Remarks

II Symptomatology and Psychodynamics

14 Averted Schizophrenia: Relation between Psychosis and Psychoneurosis

15 The Break with Reality

I General Views of Schizophrenic Cognition

II The Principle of Progressive Teleologic Regression

16The Cognitive Transformation

I Minor and Not Necessarily Psychotic Alterations

II Paleologic Thought

III Further Discussion of the Structure of Paleologic Thought

IV Teleologic Causality

V Reverse Inference and Pseudoabstraction

VI Time and Space

VII Language in Schizophrenia

VIII Very Severe Thought and Language Disorders

IX Hallucinations and Related Phenomena

X Adualism

XI Perceptual Alterations

XII The Biological Basis of Schizophrenic Cognition

 XIII Schizophrenic Thinking in Everyday Life and Everyday Thinking in
Schizophrenia

XIV Relation of Schizophrenic Thinking to Autism and to Mythical Thinking of

Cultural Origin

XV Critical Review of Various Theories of Schizophrenic Cognition

17 Disorders of Gesture, Action, and Volition

I Introductory Remarks

II Gesture

III Action

IV Volition

V Volition in Catatonics

18 Changes of the Body Image

I The Body Image

II Patients’ Experiences of Their Own Body

III Interpretation

19 The Retreat from Society

I General Remarks

II Reviews of Theories on Desocialization

III Symbolization and Socialization in a Developmental Frame of Reference

 IV Desocialization and Inner Reality in Schizophrenia

20 Creative Activities of Schizophrenic Patients: Visual Art, Poetry, Wit

I Introduction and Historical Review

II General Remarks about Schizophrenic Art

III Content and Conflict

IV Progression of Illness as Revealed by the Artwork

V Crystallization of Primary Process Mechanisms

VI Artwork of Patients Suffering from Schizophrenic-Like Toxic Psychoses

VII Relation of Schizophrenic Artwork to Primitive, Ancient, and Modern Art

VIII Poetry

IX Comedy and Wit

21 Emotional Change and Expansion of Human Experience

I Emotional Impairment and Desymbolization

II Enlargement of Human Experience

22 The First, or Initial, Stage

I Introductory Remarks

II The Onset of the Psychosis: Sequence of Early Substages

23 The Second, or Advanced, Stage
I Crystallization versus Disintegration

II The Advanced Period of Schizophrenia and Institutional Life

24 The Third, or Preterminal, Stage

I Introductory Remarks

II The Hoarding Habit

III The Self-Decorating Habit

25 The Fourth, or Terminal, Stage

I Primitive Oral Habits

II Perceptual Alterations

26 Recapitulation and Interpretation of Schizophrenic Regression

27 Heredity and Constitution in Schizophrenia

I Introductory Remarks

II Statistical Studies

III Studies of Specific Families

IV Chromosomal and Other Physical Data

V Review of Additional Studies and Interpretations

VI Conclusions
 VII Constitutional Factors in Schizophrenia

28 The Biochemistry of Schizophrenia

I Introductory Remarks

II The Transmethylation Hypothesis

III The Ceruloplasmin, Taraxein, and Related Hypotheses

IV The Serotonin Hypothesis

V The DMPEA Hypothesis and Serum Proteins

VI Other Metabolic Changes

29 Endocrine and Cardiovascular Changes in Schizophrenia

I The Endocrine Glands

II The Cardiovascular Apparatus

30 The Central Nervous System in Schizophrenia

I Neuropathology

II Electroencephalographic Findings

III Schizophrenia and Epilepsy

IV The Possibility of Psychosomatic Involvement of the Central Nervous

System in Schizophrenia

31 Epidemiology of Schizophrenia
 I Introductory Remarks

II Some Vital Statistics

III Schizophrenia Among Immigrants and Minority Groups

IV Ecology and Social Class

V Urbanism and Industrial Society

VI Concluding Remarks

32 Transcultural Studies of Schizophrenia

I Introductory Remarks

II Differences in Symptomatology

III Syndromes Related to Schizophrenia occurring More Frequently in Foreign

Countries than in the United States

33 The Prevention of Schizophrenia

I Introduction

II Basic Prevention

III Longitudinal Prevention

IV Critical Prevention

34 The Choice of Treatment

I Hospitalization versus Ambulatory Treatment
 II Physical Therapies versus Psychotherapy

III Comparison of Different Results

IV Therapies Not Described in This Book

35 The Psychotherapeutic Approach to Schizophrenia: A Historical Survey

I Freud and the Freudian School

II The Kleinian School

III Sharing the Patient’s Vision of Reality

IV Frieda Fromm-Reichmann and Her School

V Miscellaneous Contributions

36 Establishment of Relatedness
I Introduction

II The Therapeutic Encounter

III Transference

IV Countertransference

V Relatedness

37 Specific Solutions of Psychotic Mechanisms

I Introductory Remarks
 II Hallucinations

III Ideas of Reference, Delusions, and Projective Mechanisms

IV Awareness of the Punctiform Insight

V Awareness of Abnormal Cognition

38 Psychodynamic Analysis
I Introduction

II Analysis of Relations with Members of the Family

III Special Delusional Mechanisms

IV Psychodynamic Analysis of Relatedness, Transference, and

Countertransference

V Interpretations Related to the Self-Image

VI Dreams

39 Other Aspects of Psychotherapy

I Participation in Patient’s Life: The Therapeutic Assistant

II Advanced Stage of Treatment

III Complications

IV Precautionary Measures: Legal Responsibility

V Further Growth of the Patient and Termination of Treatment

 VI Cure and Outcome

VII Relations with the Family and Family Therapy

VIII Rehabilitation

40 Two Cases Treated with Intensive Psychotherapy

41 Psychotherapy of Chronic Schizophrenia

I Definitions: Scope of the Problem

II Methods of Social Interaction

42 Drug Therapy
I Introduction and Historical Notes

II Chemical Structures of the Phenothiazines

III Chlorpromazine

IV Side Effects and Complications of Chlorpromazine Therapy

V Other Phenothiazines

VI Other Neuroleptics

VII Other Types of Drug Therapy

43 Other Physical Therapies

I Convulsive Shock Treatment
 II Insulin Treatment

III Some Notes on Psychosurgery

44 Syndromes Related to Schizophrenia

I Paranoia

II Anorexia Nervosa

III Childhood Schizophrenia

45 The Concept of Schizophrenia

I Attacks on the Concept of Schizophrenia

II Three Additional Theoretical Frameworks

III Concluding Remarks

Bibliography
TO THE MEMORY OF MY PARENTS
Dr. Elio and Ines Arieti
 Preface
Since the first edition of this book appeared in 1955, psychiatry has greatly expanded,
as has the specific field of schizophrenia. When I look at the first edition, I realize how

much I have learned in the intervening years, especially in psychodynamics, in

schizophrenic cognition, and most of all in therapy. Although some basic orientations
and salient points that were expressed in the first edition—for example, the

psychodynamic mechanisms of childhood and adolescence, the structural analysis of

schizophrenic thought and language, and the development of the catatonic process—

remain valid, much has been added that permits a deeper understanding.

A new edition was long overdue. This volume has been almost completely

rewritten. From the original volume I have retained the material that I consider still

pertinent and illustrative, but I have expanded all parts of this vast subject. In order to

give a more comprehensive character to the present work, I have also added new
sections that may be useful to the beginner. These include the manifest

symptomatology of the disorder, its sociocultural and epidemiological aspects,

prevention of the psychosis, and genetic and other somatic studies.

Different parts of this work will have different relevance for various readers, in

accordance with their predominant interest. The didactical presentation of

psychotherapy in Part Seven has been particularly expanded. I have added many new

ways of dealing therapeutically with psychotic problems, and I have included detailed

reports of cases treated with intensive and prolonged psychotherapy. As in the first

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edition, especially in dealing with psychodynamics and psychotherapy, I have used a
simple style shorn of almost all technical terminology. Some aspects of this subject

have not been included, because I felt I did not have enough experience with them.

Group and hospital milieu therapy have been omitted, and references to childhood
schizophrenia have been reduced to a minimum.

This book is the result of thirty-three years of my life, spent to a large extent in
studying and in treating schizophrenia. A third of a century, from the zest of age

twenty-six to the maturity of fifty-nine, is a long time; but I believe it was spent in a

worthwhile way. I often tell my students that to study schizophrenia deeply means to
study more than half the field of psychiatry, because most problems pertaining to

schizophrenia are connected with other psychiatric conditions as well. But, as I have

tried to show throughout this book, the study of schizophrenia transcends psychiatry.

No other condition in human pathology permits us to delve so deeply into what is

specific to human nature. Although the main objective of the therapist of the
schizophrenic is to relieve suffering, he will have to deal with a panorama of the

human condition, which includes the cardinal problems of truth and illusion,

bizarreness and creativity, grandiosity and self-abnegation, loneliness and capacity for
communion, interminable suspiciousness and absolute faith, petrifying immobility and

freedom of action, capacity for projecting and blaming and self-accusation, surrender

to love and hate and imperviousness to these feelings.

To the persons mentioned in the preface to the first edition I could add a long

list of people from various parts of the world who have stimulated ideas in me or given

me material from patients. I shall mention only Drs. Hyman Barahal, Valentin

www.freepsychotherapybooks.org 19
Barenblit, William Bellamy, Henry Brill, and Giuseppe Uccheddu.

As I reflect on the difference between this work and the other one that has

required a great deal of my time—the editorship of the American Handbook of

Psychiatry —the following thought emerges. In the preparation of the Handbook,

especially in the six volumes of the second edition, I endeavored, with the help of co-

editors, to bring together a few hundred authors, specialists in the various fields. We
all worked together in an effort to prepare a worthy representation of American

psychiatry.

The present book, however, is the work of one man. Although I learned much
from teachers, colleagues, and other writers, I paved my own way down the various

avenues of this vast subject. I am pleased that I did not find it necessary to seek

financial support from either taxpayer money or foundation funds. Thus, for the

errors, as well as for the new insights expressed in these pages, I alone must be held

accountable. Be lenient, reader, but not too much; for I was not alone in this thirty-

three-year work. Always with me was the sufferer, who sooner or later gave me the

gift of trust.

SILVANO ARIETI

New York, 1974

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 Acknowledgments
I wish to express my indebtedness to the publishers who have permitted the

reproduction in this volume of long excerpts and/or illustrations from the following
articles of mine:

“Special Logic of Schizophrenic and Other Types of Autistic Thought.” Psychiatry, Vol. 11, 1948,
pp. 325-338.

“The ‘Placing into Mouth’ and Coprophagic Habits.” Journal of Nervous and Mental Disease. Vol. 99,
1944, pp. 959-964.

“Primitive Habits in the Preterminal Stage of Schizophrenia.” Journal of Nervous and Mental
Disease. Vol. 102, 1945, pp. 367-375.

“The Processes of Expectation and Anticipation.” Journal of Nervous and Mental Disease. Vol. 106,
1947, pp. 471-481.

“Autistic Thought. Its Formal Mechanisms and Its Relationship to Schizophrenia.” Journal of
Nervous and Mental Disease. Vol. Ill, 1950, pp. 288-303.

“The Possibility of Psychosomatic Involvement of the Central Nervous System in Schizophrenia.”

Journal of Nervous and Mental Disease, Vol. 123, 1956, pp. 324-333.

“Volition and Value: A Study Based on Catatonic Schizophrenia.” Comprehensive Psychiatry, Vol. 2,
1961, pp. 74-82.

“Schizophrenic Thought.” American Journal of Psychotherapy, Vol. XIII, 1959, pp. 537-552.

“Hallucinations, Delusions, and Ideas of Reference.” American Journal of Psychotherapy, Vol. 16,
1962, pp. 52-60.

www.freepsychotherapybooks.org 21
“The Schizophrenic Patient in Office Treatment.” Psychother. Schizophrenia, 3rd International
Symposium, Lausanne, Switzerland, 1964, pp. 7-23. (Karger)

“Schizophrenic Art and Its Relationship to Modern Art,” Journal of the American Academy of
Psychoanalysis, Vol. 1, pp. 333-365. © 1973 by John Wiley & Sons.

Permissions for reproductions of illustrations were obtained from Dr. Hyman

Barahal, Dr. Valentin Barenblit, Professor Jean Bobon, Dr. Enzo Gabrici, and Professor

Giuseppe Uccheddu.

www.freepsychotherapybooks.org 22
 PART ONE

The Manifest Symptomatology and Other Basic

Notions

CHAPTER
1
The Basic Questions
What is schizophrenia? How can it be recognized, interpreted, and treated? These

basic questions are posed not only by the beginner in the field of psychiatry, but also

by the professional who has spent the major part of his life treating psychiatric

patients. A serious attempt will be made here to answer these difficult questions. Our

long search will lead us in various directions. We shall not just collect and integrate

what we know; we shall explore new areas and revisit old ones with new eyes. Even
when definite conclusions will not be reached, we shall be aware that we have tried to

broaden our views of man, of his suffering, and of his potentialities.

The basic questions we have posed imply that we cannot start our didactical

journey with the standard procedure, that is, by defining our major theme. It is a

formidable task to define schizophrenia unless we accept an unsatisfactory definition

www.freepsychotherapybooks.org 23
that consists of a list of the most common characteristics of the disorder. More
appropriate definitions will be attempted several times in this book, after we have

examined the subject from several perspectives.

Some authors consider schizophrenia an illness, others a syndrome, still others

a mental mechanism or even a way of living. There is some truth in each of these

views, and yet at closer analysis all of them prove to be unsatisfactory. The

understanding or the clarity that they seem to offer reflect the facility of approaches

that take into consideration only one or a few aspects of a complicated problem.

Certainly schizophrenia is a way of living, but so is having a heart murmur, being a

doctor, a nurse, remaining a bachelor, and so on. As we shall elaborate in other

chapters of this book, the authors who call schizophrenia a way of living probably

want to stress that it is a natural and enduring way of living, an appropriate response

to certain environmental situations. This seems hardly the case to those who have

witnessed the suffering that accompanies this special “way of living.”

There are particular mental mechanisms in schizophrenia, but these have to be

understood in their origins and consequences. Schizophrenia, of course, can be

considered a syndrome; but again, which symptoms are the essential ones in a

condition that presents itself in multiple ways? Moreover, what is the interrelation

between the various symptoms? Could we say about schizophrenia something

comparable in clarity to what we can say about diabetes, whose symptoms can be

understood as consequent to a disorder of the carbohydrate metabolism?

Can we state that schizophrenia is an illness? If we follow the concepts of

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Virchow, or those derived from Virchow, which imply cellular pathology, an
understanding of the pathological mechanisms, and the capacity to reproduce
experimentally the condition, the answer is no. Apparently this negative answer is

stressed by those authors who conclude that schizophrenia is not an illness, but

probably only a special way of coping with life. Once more a semantic controversy

complicates the issue. If we define disease as a state in which bodily health is

impaired, we cannot at present call schizophrenia a disease because there is no

uncontroversial evidence of bodily impairment. If by disease we mean an undesirable

state of the subject, resulting in alterations of his basic functions, including the

psychological, then schizophrenia is certainly a disease. Schizophrenia, as well as most

mental illnesses or psychiatric conditions, does not fit the medical (especially

Virchowian) model. This realization does not necessarily lead to the conclusion that

the concept of schizophrenia or any mental illness is a myth. An alternative position is

that the traditional medical model was built without taking psychiatry into

consideration and does not include all the dimensions of human pathology. If we do

change the traditional medical model, we can then call schizophrenia an illness. The
big issues, however, remain untouched. What kind of illness? What is its nature?

Generally we consider schizophrenia a special type of illness (or disease or

syndrome)—a psychosis. There are as many obscurities about the concept of

psychosis as there are about the concept of schizophrenia, although the term psychosis

refers to a broader category, to which schizophrenia belongs. As I expressed

elsewhere (Arieti, 1973), psychosis is a term generally used to designate a severe or

major psychiatric disorder. In theory and clinical practice the concept is more difficult

to define because severity is not an inflexible characteristic and a certain number of

www.freepsychotherapybooks.org 25
cases diagnosed as psychosis may in fact be less serious from the point of view of the

sufferer or of society than are some of those included in other psychiatric categories.

The term psychosis is at times indistinctly equated with insanity. The latter term, when

used legally or in popular language, suggests a person who is so incompetent that he

may require special control or supervision. However, psychosis indicates not only

actual or potential severity, but also connotes that an unrealistic way of appreciating
the self and the world is accepted or tends to be accepted by the sufferer as a normal

way of living. At any rate, typical psychotics who are not under treatment do not seem
to know that there is anything wrong with them. This definition of psychosis lends

itself to justified criticism because it implies that we know what is unreality or

unrealistic.

This book will deal with the various biological and psychological approaches

that have been applied to the problem of schizophrenia. It will pursue chiefly the

psychological approach, which, in my opinion, has so far provided an understanding

more significant than that provided by the other methods. Moreover, the practicing

psychiatrist, even if he prefers physical methods of treatment, cannot help trying to

understand the psychodynamics of the case and to practice some kind of

psychotherapy.

All the methods that have been followed so far in this field have been rewarding

to varying degrees. The simplest approach is the descriptive and taxonomic. With this
method, the symptoms of the patients are recognized, described, and labeled. They are

observed in their manifest aspect, that is, as they present themselves to a clinical

examination without any physiologic or symbolic meaning being attached to them.

www.freepsychotherapybooks.org 26
Whereas this method was the only one at a certain stage in the history of psychiatry, it
must today be considered as the initial and most elementary approach, even though it

is still valuable. Contrary to old treatises of psychiatry, which dealt almost exclusively
with this aspect of the disorder, this book will deal with it only in Chapters 3 and 4.

The dynamic approach initiated an era of greater and deeper understanding.

The symptoms came to be interpreted as having a meaning; the symptomatology came

to be seen as having a purpose and a genetic history as well, inasmuch as it could be

related to the previous, predominantly early, life history of the individual. It is

impossible to overestimate the value of the dynamic approach in schizophrenia and, of

course, in psychiatry in general. Nothing could be more important from a

psychotherapeutic point of view. One of the major parts of this book (Part Two) will be
devoted to this dynamic interpretation, as a necessary preparation to psychotherapy,

which will be dealt with in Part Seven. In the first chapters of Part Two (Chapters 5-8)
we shall accompany the patient from birth to the onset of the psychosis. In the

remainder of Part Two (Chapters 9-14), with the help of case histories, we shall

examine the dynamisms occurring in the main types of schizophrenia, such as the

paranoid, catatonic, hebephrenic, postpartum, and so forth. We shall be able to

individualize patterns that tend to recur, that build to a crescendo of conflict and

maladjustment, and that eventually lead to a disintegration of the defenses. This

psychodynamic study will involve the patient in his intrapsychic life as well as in

relation to his environment.

And yet we shall come to recognize that even this dynamic approach, in spite of

the profound insights that it offers to the therapist, does not solve in its entirety the

www.freepsychotherapybooks.org 27
mystery of this mental disorder. Even when the symptoms are explained in their
symbolic language, even when their motivation is understood, even when their

relation to early life situations has been established, there is still a great deal that
needs explanation. Why is the schizophrenic pattern so different from any other? Why

have the symptoms such peculiar aspects? Why does the patient experience

hallucinations and delusions? Why does he present word salad, catatonic postures,

stereotyped activities, and so forth? Even if we accept the fact, and we do accept it, that

the psychological traumata in schizophrenia were more violent and more destructive
than in patients who develop psychoneuroses, we are not able, with a dynamic

approach, to understand the formal structure of the symptoms. When a regressed

schizophrenic replies, “White House,” to the question “Who was the first president of

the United States?” how is the disorder implicit in the answer to be interpreted?

Bleuler would call the phenomenon a “loose association,” but this term is more

descriptive than explanatory. A dynamic approach clarifies the underlying motivation

that has led to the selection or facilitated the occurrence of the process, but this
approach does not explain the mechanisms of the process itself.

The first edition of this book (1955), pursuing some studies started in the early
1940s, pioneered an additional approach to schizophrenia. This approach, called

structural or psychostructural, aimed at the understanding of the psychological

structure, was developed independently and along different lines from the studies of

Levi-Strauss and preceded Chomsky’s application of structuralism to other fields of

inquiry. In this second edition the importance of the structural approach is reaffirmed

and expanded.

www.freepsychotherapybooks.org 28
 In psychiatry the structural approach must be related to the dynamic; and the

way in which dynamic factors use, exploit, and change the formal mechanisms must be
determined.

The structural approach does not aim at a description, as the descriptive

approach does, but at an understanding of the mechanisms of the psychological

functions. This approach remains at a psychological level and is not necessarily

concerned with, although it may lead to, studies of the organic basis of the psychic

functions.

The dynamic and the structural approaches differ also in certain other respects.

The structural approach emphasizes what patients have in common, and the common

psychological mechanisms that they adopt. Although it does not do so exclusively, the

dynamic approach studies predominantly what is specific in each case; the more

specific are the elements studied, the more accurate and therapeutically useful they
are. Both approaches must be used, because both are valuable. Every schizophrenic,

like every man, is both similar to, and different from, other patients and men. Here
again is that fundamental dichotomy—similarity and difference—on which all human

understanding is based.

The psychostructural approach, which we shall study in Part Three, makes us

enter into the world of schizophrenia. It reveals how the patient feels, thinks, acts, and

relates, and how he experiences his own body, the inanimate world, art, work, the

passage of time, and the looming of space. It focuses on those parts of the human being

that are particularly human: symbolism, as expressed in imagery, language, thinking,

www.freepsychotherapybooks.org 29
interrelations; and volition, as expressed in choice and actions. The schizophrenic
deformations will reveal themselves as psychodynamic conflicts that have assumed
unusual and yet interpretable forms.

Whereas the dynamic approach remains predominantly a psychiatric study, the

formal or psychostructural approach transcends the field of psychiatry. Excursions

into other fields, such as anthropology, sociology, logic, aesthetics, neurology, and

general biology, are necessary. The results obtained concern not only psychiatry, but

all the sciences whose subject is the nature of man. Part Three will also disclose the
influences of people who have made significant contributions in various fields—for

example, Giambattista Vico, Hughlings Jackson, George Mead, Kurt Goldstein, Jean
Piaget, Heinz Werner, and Susanne Langer.

The study of schizophrenia is not complete without taking into consideration

the cases that proceed toward chronicity. Fortunately, these cases today are sharply

decreasing in number. Although their response to treatment is by far inferior to that of

recent cases, the psychiatrist must have some knowledge of them in order to

understand the aspects of the schizophrenic phenomenon that are not revealed in less

advanced cases. Part Four will be devoted to the longitudinal study of schizophrenia

from the earliest to the most advanced stages. Many books on schizophrenia have
failed to offer a detailed description and interpretation of the gradual progression of

the illness. In Part Four, interpretation of some individual symptoms as well as of the

whole phenomenon of regression will be offered.

The psychodynamic, psychostructural, and longitudinal approaches cover vast

www.freepsychotherapybooks.org 30
dimensions. Whatever they reveal seems necessary for the engendering and unfolding
of schizophrenia. However, many psychiatrists doubt that these necessary factors are
sufficient to cause or explain the disorder. Many researchers in the field have

accumulated a vast amount of data, from the genetic code to biochemical changes.

Most of the physiologic and organic changes reported in schizophrenic patients have

been studied almost exclusively from the point of view of demonstrating the organic
origin of this condition. In several, but not all, instances the possibility exists that these

changes are only the result of the disorder. In some respects these changes may be
psychosomatic, that is, they may be sequences of the primary psychological condition.

Part Five of this book will be devoted to the somatic and psychosomatic study of

schizophrenia.

Part Six will deal with the social, cultural, and epidemiological factors favoring

the occurrence of the psychosis. This discussion will not be exhaustive, but will cover

the material that is most pertinent to the practicing psychiatrist.

The first six parts of the book will reveal how our knowledge of schizophrenia

has been vastly enlarged, even in the past few years, but they will also show that all

the links have not yet been placed in the right sequence in the great chain of causes

and effects. Final syntheses remain to be made. In spite of the incompleteness of our
understanding, I think that the reader can approach Parts Seven and Eight, devoted to

therapy, with a definite sense of optimism. Our understanding of the disorder is

sufficient to permit a totally successful treatment of many patients and a marked

amelioration in many others.

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 After a discussion of the choice of treatment, Part Seven will deal with

psychotherapy. What has been learned predominantly from the dynamic and
structural approaches, but also from all the other studies of schizophrenia, will be

applied to psychotherapy. This is the method in which I have my largest experience,

and so it will be described in greatest detail. The physical treatments, and in particular

drug therapy, will be described in Part Eight.

Part Nine will reconsider the scope and extent of schizophrenia. Are such

conditions as paranoia, child schizophrenia, and anorexia nervosa to be included in the

great parameter of the disorder? After reexamining some theoretical concepts, I will
attempt a recapitulation and synthesis of the basic concepts expressed in this work.

Before undertaking these studies, we shall review in Chapter 2 the evolution of

the major concepts of schizophrenia, from the earliest formulations of the disorder to

those preceding the publication of the first edition of this book.

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 CHAPTER
2
Historical Review of the Concept of Schizophrenia
A critical review of the changing concepts of schizophrenia will be attempted in this

chapter. This review will not be a complete one; it will not include the pre-

Kraepelinian conceptions, which now have only a historical interest; and it will omit
entirely all those theories which have received transient and inconsequential

consideration. The contributions published since 1955 will be discussed in the

subsequent chapters of this book, in relation to the various aspects of the disorder.

The contributions examined in this chapter are those of six authors who, in my

opinion, are responsible for the evolution of the concept of schizophrenia from 1896

to 1955. These innovators are Kraepelin, Bleuler, Meyer, Freud, Jung, and Sullivan. A

host of contributions, some of them very valuable, have been stimulated directly or

indirectly by the works of these six men; and the reader who is interested may find an

account of them elsewhere (Lewis, 1936; Beliak, 1948, 1957; Benedetti, Kind, and

Mielke, 1957; Beliak and Loeb, 1969; Cancro, 1971, 1972).

Although our purpose here is to discuss six different views of schizophrenia, it is

obvious that these views in respect to this condition reflect conceptions toward the

entire field of psychiatry, or toward the human psyche, and therefore we cannot help
in several instances to refer to other psychiatric areas. These six views have enlarged

our understanding of schizophrenia almost exclusively in a psychological frame of

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 reference. Some of the mentioned authors worked and theorized from an organic

point of view also, but only their work in the psychological areas has retained

significance. For instance, Kraepelin’s hypothesis about metabolic-toxic disorders in

schizophrenia did not produce the same repercussions that his clinical description of

the psychological manifestations did.

In contrast with the relatively nonextensive work of these six authors is the

immense amount of the work of countless researchers who have attacked the

schizophrenic enigma from a predominantly organic point of view. These researchers

have followed the assumption that in the study of schizophrenia, as in the study of
other diseases in biology, one should follow Virchow’s concept that any kind of

pathology means organic or cellular pathology. Under the influence of this concept,
which for a long time has dominated the whole field of medicine, researchers have

examined every possible spot of the body of the schizophrenic patient from top to

bottom, from the hair to the sexual glands, in a relentless attempt to find clues that

would reveal the organic nature of this condition.

Even at present the organic studies of schizophrenia outnumber by far the

psychological ones. The most important of them, or those that at least promise to open

constructive avenues of research, will be discussed in Part Six.

Emil Kraepelin

Emil Kraepelin (1855-1926) was the first psychiatrist to differentiate from the
mass of intramural mental patients that pathological entity which he called dementia

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praecox. He did so in 1896, although the namt dementia praecox had already been used
by Morel in 1860 and by Pick in 1891. Morel described his first case in a 14-year-old
boy, and for him the word praecox meant that the demential state started early, or

precociously, in life, in contrast to senile dementia, which occurred in old age.

Kraepelin, too, following the observation of Hecker, used the term praecox to refer to

the fact that the condition “seemed to stand in near relation to the period of youth.” In
Kraepelin’s writings and in the Kraepelinian approach, however, the term praecox

acquired, explicitly or by implication, an additional meaning: the state of dementia was

supposed to follow precociously or soon after the onset of the illness. Thus even in the

name of the disease, as used by Kraepelin, one recognizes his finalistic conception: the

fundamental characteristic of the disease is its outcome, a prognostic characteristic.

The major contribution of Kraepelin was the inclusion, in the same syndrome, of

catatonia, already described by Kahlbaum, hebephrenia, and “vesania typica,” also

described by Kahlbaum, characterized by auditory hallucinations and persecutory

trends. After examining and observing thousands of patients, and seeing them
panoramically in space and time, Kraepelin was able to discern the common

characteristics in these apparently dissimilar cases. The characteristic that impressed

him most was the progressive tendency toward a state of dementia. The other patients
who did not have this tendency, like the manic-depressives, would be separated from

the praecox group and subsequently would be recognized as having other differential

symptoms also. Using this method of observation, Kraepelin could differentiate and

define as dementia praecox a symptomatology consisting of hallucinations, delusions,

incongruous emotivity, impairment of attention, negativism, stereotyped behavior,

and progressive dilapidation in the presence of relatively intact sensorium.

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 In England, Thomas Clouston, in an impressive address that he delivered in

1888 as president of the Medico-Psychological Association, spoke of “adolescent

insanities” and offered a description in many respects comparable to Kraepelin’s.

However, he did not separate the praecox cases from the manic-depressive, which at

that time occurred quite frequently. Thus there is no doubt that Kraepelin deserves to

be considered the first author who differentiated the disorder.

Once he defined this syndrome, Kraepelin tried his best to give an accurate

description of it. Like a man working at a microscope, he described as many minute

details as possible. His monograph Dementia Praecox and Paraphrenia (1919) remains
until today the most complete description of the symptoms of the schizophrenic from

a phenomenological point of view. The symptom is described and accepted as it is,

with no attempt being made to interpret it, either physiologically or psychologically.

Some symptoms (for instance, negativism) were described for the first time by

Kraepelin.

Kraepelin also divided the patients into three groups: the hebephrenic, the
catatonic, and the paranoid. Later, he accepted the differentiation of a fourth type, the

simple, as suggested by other authors. He also separated from dementia praecox, a

new nosological entity, “paraphrenia.” In this syndrome, too, the outcome is the

fundamental consideration: in spite of the progression of the illness, there is no decay

of the personality. As to the etiology, Kraepelin considered dementia praecox an

endogenous illness, that is, one not due to external causes. At first he thought it was

due to organic pathology of the brain; later he felt that it might be due to a metabolic

disorder.

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 The great merit of Kraepelin consists in his having been able to synthesize

successfully the works of Kahlbaum, Morel, Wundt, and others, and to organize them
in his own system. We cannot fully appreciate his influence until we read a book of

psychiatry of the pre-Kraepelinian era and evaluate the confusing picture of

psychiatry in those days. Today it is impossible, however, not to see the shortcomings

of Kraepelin’s conceptions of dementia praecox. The acceptance of the prognostic

characteristic as the fundamental one cannot be considered a sound principle. First, as

Kraepelin himself came to recognize, not all cases of dementia praecox end in

dementia; as a matter of fact, some of them seem to make a complete recovery.

Secondly, this finalistic or teleologic point of view is incompatible with the scientific

method, which searches for the causes and not for the effects.

Although Kraepelin himself was probably unaware of this influence, this overall

prognostic concept reinforced the popular fatalistic attitude toward mental illnesses

and discouraged therapeutic attempts. Reading his monograph on dementia praecox,

one cannot help admiring the accurateness of his description; however, his description

is remarkable for its extension and completeness, not for its depth. The patient
appears as a collection of symptoms, not as a person; or, if he appears as a person, he

looks as if he belongs to a special species and thus should be differentiated from the

rest of humanity and put into the insane asylum. The psychiatric hospital is a

zoological garden with many differentiated species.

Kraepelin seems to see the patient as detached or to be detached from society. It

never enters his mind that the schizophrenic may have been influenced by social

forces, or may even be a product of society. Although his fundamental concept was the

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final outcome, that is, a temporal concept, he does not give a longitudinal picture of the
patient. Except for the repeated mention of the fact that the patient decays

progressively until he reaches a state of idiocy, we do not see in the Kraepelinian

description different stages or any real movement, even toward regression. The

patient is always seen in cross section.

It is often said that Kraepelin was more concerned with the structure of the
psychic phenomena than with the content, that he was more concerned with how the

patient thinks than with what he thinks. Undoubtedly he was not concerned with the

psychological importance of the content of thought, but it seems to me that he was also

not concerned with the real structure of patients’ thoughts. A mere description of the

symptoms is not a structural understanding.

When we examine the negative qualities of Kraepelin’s conceptions, we are

bound to be too harsh with him. It is really too easy for us to see what he did not see.

Nobody would criticize Galileo for not knowing the principles of electricity. If we

concentrate on what Kraepelin did not give us, in comparison to others like Freud or

Bleuler, we are bound to minimize his accomplishments, which are immense.

Kraepelin may be viewed as the Linnaeus of psychiatry, in comparison to Freud,

who may be viewed as the Darwin. But as Linnaeus and Darwin were necessary in the

development of biology, so both Kraepelin and Freud were necessary in the

development of psychiatry. A great deal of resentment toward Kraepelinian

psychiatry, which may be noted in some psychiatric circles, is due, actually, not to an

attempt to minimize Kraepelin’s accomplishments, but rather to a displeasure with the

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 tenacity with which his concepts have been retained, even long after more penetrating
ones have been formulated. Zilboorg (1941) wrote that “the system of Kraepelin
appears to have become a thing of the past as soon as it announced its own birth in

1896.” In a certain way this is true, because Sigmund Freud published his first

outstanding book in the same year. On the other hand, one may say that even today

Kraepelinian psychiatry is the best known in the world. Thousands and thousands of
patients are still viewed and classified as Kraepelin taught, and until the middle 1940s,

in the United States, too, they were still labeled with the name dementia praecox. [1]

Eugen Bleuler

Kraepelin’s contributions were not accepted without objections. Among the

well-known psychiatrists who opposed most of his views were Ernest Meyer,

Korsakov, Bianchi, Serbsky, and Marandon de Montyel.

Eugen Bleuler (1857-1930), a Swiss psychiatrist whose role in the history of

psychiatry will remain an important one, accepted much of Kraepelin but revitalized
the Kraepelinian concepts and revised them, making a strong attempt, though not a

thoroughly successful one, to go beyond a purely descriptive approach.

In 1911 Bleuler published a monograph on dementia praecox that was the

result of many years of study and research.[2] He renamed the syndrome

“schizophrenia,” implying that a splitting of the various psychic functions, rather than
a progression toward a demential state, was one of the outstanding characteristics. He

delivered a blow to the Kraepelinian concept of dementia praecox as a disease entity,

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inasmuch as he included in the schizophrenic group many syndromes that at that time
no one was prepared to consider as being related to schizophrenia. He included in the
schizophrenic group psychoses that arise in psychopathic personalities, alcoholic

hallucinoses, prison psychoses, and cases of symptomatic manic-depressive

psychoses. Furthermore, he thought that the largest number of cases of schizophrenia

are latent cases; these patients are never hospitalized because the symptoms are not
severe enough, but still they show oddities of behavior that are attributable to an

insidious schizophrenic process. As several authors have remarked (Morselli, 1955;

Stierlin, 1965, 1967), Bleuler also considered and humanized the concept of

schizophrenia by pointing out that even normal persons, when preoccupied or

distracted, show a number of schizophrenic symptoms, such as “peculiar associations,

incomplete concepts and ideas, displacements, logical blunders, and stereotypes.” He

added that “the individual symptom in itself is less important than its intensity and
extensiveness, and above all its relation to the psychological setting.”

Bleuler classified the symptoms of schizophrenia in two sets of groups: the

groups of fundamental and accessory symptoms and the groups of primary and

secondary symptoms. The fundamental symptoms are not necessarily the primary

ones; they are the symptoms that are present to an extent in every case of
schizophrenia, whether latent or manifest. The accessory symptoms are those that

may or may not occur. Among the fundamental symptoms Bleuler included the

disorder of the process of association, which he considered the most important

characteristic of schizophrenia, and also a particular type of thinking and behavior

that he called autism. Among the accessory symptoms he included the acute

manifestations of the psychosis, like delusions, hallucinations, catatonic postures, and

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so forth. Primary symptoms are directly related to the disease process; they are the

necessary phenomena of the disease. The most important of them is again the

association disorder. Secondary symptoms are caused by a combination of the action

of the primary ones and the action of psychogenic factors.

The most important contributions of Bleuler were those related to his study of

the process of association and disturbances of the affective life, the concepts of autism

and ambivalence, and his interpretation of negativism.

The disorder of the process of association, according to Bleuler, involves every

aspect of schizophrenia. Whereas, on the one hand, Bleuler enlarged the concept of

schizophrenia by making the Kraepelinian nosological entity less rigid and less

specific, he tried, on the other hand, to individualize the essential mechanism of the

schizophrenic process. He thought that it consisted of a loosening of the associations

of ideas. This mechanism may range from a maximum, which corresponds to complete
incoherence, to a minimum, which is hardly perceptible. He writes: “. . . single images

or whole combinations may be rendered ineffective, in an apparently haphazard

fashion. Instead, thinking operates with ideas and concepts which have no, or a

completely insufficient, connection with the main idea and therefore should be

excluded from the thought process. The result is that thinking becomes confused,

bizarre, incorrect, abrupt. . . Bleuler described accurately the various degrees of this

associative disorder and related symptoms such as blocking, elisions, logical errors,
and so on, but he was not able to infer any underlying basic formal mechanism. He

limited himself to the formulation that these symptoms were the result of a loosening

of associations. As far as their motivation was concerned, Bleuler accepted Freudian

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mechanisms quite often. Blocking was seen by him as an exaggeration of repression.
He felt that psychological complexes might explain the combinations of ideas in a

condensed or bizarre pattern. He accepted the Freudian concept of unconscious

motivation and of symbolism, especially in explaining hallucinations and delusions. He

thought that delusions result, not from a defect in logic, but from an inner need. At the

same time, he expressed the opinion that it was not enough to explain everything with

dynamic processes.

Bleuler went further than Kraepelin; he wanted to explain symptoms in respect

to their psychological content as well as their structure. As to the content, he accepted

Freud’s explanations. He realized, however, that these were not enough; and although

he was not able to formulate clearly what was missing in the Freudian approach, it is
obvious that he searched for a structural or formal explanation of the symptoms, that

is, he would have liked to have known why the symptoms have specific manifestations
in schizophrenia. He tried to solve the problem by assuming that the structural defect

involved always the loosening of associations; but he could not go beyond this point,

and therefore his formal studies remained as descriptive as Kraepelin’s. Although he

might have been influenced by Wernicke’s “concept of sejunction,” Bleuler did not
attempt to give an anatomical interpretation of the symptoms. On the other hand,

because he could not explain everything with Freudian mechanisms, he could not

dismiss the idea that schizophrenia might be due to an underlying organic disease. In

his book he mentions the possibility that mental causes produce the symptoms, but
not the disease. He states that the disease process may be due to some kind of toxin, as

is rheumatism. Thus, Bleuler himself is a good example of that ambivalent attitude

which he was the first to describe; he expresses the feeling that schizophrenia is a

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psychogenic disorder, and yet he cannot dispel the idea that it may be organic in

origin.

This concept of ambivalence, which Bleuler first described in psychotics, has

since played an important role in psychiatric thinking, not only in reference to

psychotics, but also in reference to neurotics and normal human beings. By

ambivalence Bleuler meant the simultaneous occurrence of two opposite feelings for

the same object, such as in the case of the husband who both loves and hates his wife.

He found this symptom in every schizophrenic and thought that the most marked form

of it was inherent in catatonic negativism. Shortly after the publication of his major

book, Bleuler became less ambivalent and, as Stierlin (1967) put it, grew “defensive
about his Freudian leanings.” He strongly reiterated that only symptoms may come

about in the ways described by Freud and Jung, but the illness itself was probably the

result of organic causes, as Kraepelin had postulated (Bleuler, 1913 b).

Bleuler thought that the affective disorders that occurred in schizophrenia were

not primary but secondary. He was one of the first to note that when the patients'

complexes were involved, the feelings of the patients were normal or even

exaggerated. He also noticed that patients who appeared completely apathetic were

capable of complete or partial recoveries. He saw the apparent loss of affect as due to

repression.

The concept of autism is another of Bleuler’s major contributions. He used this

term to refer to a certain tendency to turn away from reality, accompanied by a certain

type of thinking. Autistic thinking, according to Bleuler, as opposed to logical thinking,

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does not represent occurrences in the outer world and their associations; as a matter
of fact, it excludes many external and internal facts. The autistic patient tends to live in
a world of fantasy, where symbolization is used constantly. Autistic thinking is not

bound by the laws of logic and reality. “It is unlogical and permits the greatest

contradictions with the outer world and in itself.” By failing to take into consideration

the facts of reality it becomes “dereistic.” The autistic person identifies wishes or fears
with reality. “The fear of having enemies is for his autistic thinking identical with the

fixed conviction that they exist.” Autistic thinking flourishes particularly in

schizophrenia, but it may occur even in normal situations: for instance, in children

when they play; in subjects that are not sufficiently accessible to our knowledge and

our logic, such as religion, love; or wherever the emotions “obtain too great a

significance” (Bleuler, 1913a).

Undoubtedly it is to Bleuler’s credit that he defined and described this type of

thinking, which is so different from what is generally called logical thinking. However,

it must be remembered that fundamentally Bleuler has given us only a description of

it. Here again it should be stated that he accepted Freudian interpretations in regard to

the content; from a formal point of view, he limited himself to saying that this type of

thinking was not logical. He felt that his concept of autism nearly coincided with
Freud’s concept of autoerotism and with Janet’s “loss of the sense of reality.”

As far as negativism is concerned, Bleuler thought that it could not be explained

solely as a motor phenomenon (1912a, 1950). He was inclined to consider it as a

psychological attitude. The patient considers all stimuli coming from the environment

as hostile and disturbing, and therefore he tries to block them off. This psychological

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interpretation allows for the explanation of negativism as being expressed only at
times toward certain persons. As was mentioned before, Bleuler saw the negativistic

attitude as being related to the ambivalent attitude. He also felt that intellectual
negativism might be based on a general tendency of ideas to associate with their

opposites.

Thus we may summarize the contribution of Bleuler as follows:

1. He saw the schizophrenic syndrome, not as a progression toward dementia,

but as a particular condition characterized mainly by a disorder of
association and by a splitting of the basic functions of the
personality.

2. He enlarged the boundaries of what should be included under this

syndrome.

3. He differentiated a new subtype, the simple (or simplex) type, using the
name and some of the concepts already partially advanced by
Weygandt (1902) and by Diem (1903).

4. He emphasized that affectivity is not absent in schizophrenia, and that it

plays a more important role than it was then thought.

5. He attempted not only to describe the symptoms, but to explain them. As to

their psychological content, he accepted Freud’s contributions.
From a formal point of view, his efforts have remained unfulfilled.

6. He gave psychiatry the concepts of autistic thinking and of ambivalence.

7. He enlarged the psychiatric terminology by coining the following well-

accepted terms: schizophrenia, depth psychology, autism,

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 ambivalence, and dereism.

Adolph Meyer

Adolph Meyer (1866-1950), a Swiss physician who came to the United States in

1892, was for several decades the leading American psychiatrist. Schizophrenia was
one of his major interests from the beginning of his career (Lief, 1948; Meyer, 1906,

1910, 1912a, 1912b). Meyer was dissatisfied with the role given to heredity and
autointoxication in the etiology and pathogenesis of dementia praecox. He felt that

perhaps the psychological factors to which laymen and old schools of psychiatry had

given so much importance in the past should be reconsidered.

Kraepelin had given an accurate description of the disease after the onset.

Meyer advocated that the patient be studied “longitudinally”; from the beginning of his

life, all the factors that might have contributed to the mental condition should be

searched and examined. Meyer thus became convinced that dementia praecox was the

result of an accumulation of habit disorders or faulty habits of reaction. The individual

who is not able to cope with the problems and difficulties of life, and who is

confronted with failure after failure, may tend toward what Meyer called substitutive

reactions. At first these new habits appear as “trivial and harmless subterfuges,” such

as day dreaming, rumination, decrease of interests, and so on, but later they become
harmful, uncontrollable, and tend to assume definite mechanisms, like hallucinations,

delusions, blocking, and so forth. These anomalous mechanisms, according to Meyer,

are partially intelligible as substitutions for “efficient adjustment to concrete and

actual difficulties.” Meyer felt that it was possible to formulate the main facts

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appearing in the history of most cases as a “natural chain of cause and effect.” He saw
dementia praecox as “the usually inevitable outcome of (1) conflicts of instincts, or

conflicts of complexes of experience, and (2) incapacity for a harmless constructive

adjustment.”

Meyer called his concept “dynamic,” inasmuch as it implied a longitudinal

interaction of forces; he also called it “psychobiological,” inasmuch as it considered the

psychological as well as all the pertinent biological factors. He renamed the disorder

parergasia, which etymologically means incongruity of behavior. This term, however,

has not been accepted outside of his school.

An unbiased critic may find great merits and great pitfalls in Meyer’s concepts.

The greatest merit lies in his having reaffirmed the importance of “mental” or

psychological factors in the etiology of schizophrenia. The longitudinal aspect of the

process of maladjustment, before it reaches psychotic proportions, had not been

adequately stressed before by any other school, except the psychoanalytic. In other

respects, however, Meyer’s formulations remain vague and inadequate in explaining

any specific characteristics of schizophrenia. Accumulation of faulty habits and of

repeated failures may already indicate some preexisting abnormality, either organic or
environmental. Meyer explains the progression of the habit deterioration as caused by

the gradual substitution of increasingly inferior and distorted material. Finally, the

distortions are so great that they become full-fledged schizophrenic symptoms. The
role that anxiety plays in this process is not clearly apparent from his writings.

Furthermore, how and why these faulty habits lead necessarily to schizophrenia, and

not to other psychopathological reactions, remains unexplained. Meyer seems to

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believe that there is only a gradual or quantitative difference between faulty habits
and clear-cut schizophrenic symptoms. He seems to consider the faulty habits only as

the expression of maladjustment at a realistic level; he does not stress enough the
point that what he calls substitutive habits often have a symbolic or nonapparent

meaning. Moreover he does not emphasize that schizophrenic symptoms have an

archaic or primordial aspect that is lacking in prepsychotic faulty habits.

In addition, although some schizophrenic-like or symbolic manifestations may

appear as faulty habits in everybody’s life, a constellation of them, as is found in

schizophrenia, seems typical or characteristic enough, even from a qualitative point of

view. The faulty habits that we may find in human beings are innumerable, but the

schizophrenic symptoms, from a formal point of view, are strikingly similar in every
patient. The patients do not appear only as caricatures or exaggerated expressions of

their prepsychotic personality; the greatest number of their characteristics have

undergone a drastic metamorphosis and have been channeled into few definite

patterns. In other words, if a substitution of faulty habits occurs, it is because they are

substituted by schizophrenic symptoms. Meyer’s interpretation of schizophrenia as a

substitution of faulty habits is therefore not an interpretation. In addition, those faulty

habits found in the history of many schizophrenics are found also in the history of

many psychoneurotics.

Meyer is correct in considering schizophrenia a progressive pathological

adjustment; however, from his writings one does not learn when a patient with faulty

habits is to be considered an overt schizophrenic. It may be asserted that the faulty

habits of the schizophrenic disclose some kind of malignancy that is not present in the

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faulty habits of the neurotic. This concept had led many psychiatrists to make an
accurate search for those latent schizophrenic symptoms that seem to be

psychoneurotic traits. A pseudoneurotic type of schizophrenia has even been

described (Hoch and Polatin, 1949). Because many of these patients do not move

toward either a more or less psychotic condition, it remains for the individual

observer to classify them in one way or the other.

No doubt this search for latent schizophrenia in apparent psychoneurotics has

resulted in the early diagnosis of many schizophrenics. However, this tendency is

perhaps exaggerated in some sectors and for some time may have had a deterrent

effect as far as therapy is concerned. In fact, until the early 1940s a diagnosis of

schizophrenia discouraged a psychotherapeutic approach, which Meyer himself

usually found “negative and rarely clearly positive” in these cases (Meyer, Jelliffe, and

Hoch, 1911).

Summarizing, we may state that Meyer’s major contribution was his emphasis

on a longitudinal study of the patient and on the reaffirmation of the importance of the

psychogenic factors. His approach must therefore be considered a partially dynamic

one. Its dynamism is somehow stunted by the fact that the early environmental
factors, acting during the childhood of the patient, do not receive the proper stress,

and by the fact that its symptoms are more or less considered from a realistic, that is,

nonsymbolic, point of view. The dynamic psychoanalytic point of view not only is
more complete, but actually preceded the psychobiological one historically.

Although Freud was born before Meyer, and some of the main psychoanalytic

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 concepts preceded those of the psychobiological schools, we have disregarded
chronological order and have discussed Meyer before the founder of psychoanalysis.
Conceptually, in fact, Meyer does not go as far as Freud and seems to provide a bridge

between the Kraepelinian-Bleulerian points of view and those which follow a fully

psychodynamic approach. Moreover, in the first few decades of its existence,

psychoanalysis devoted itself almost exclusively to the psychoneuroses, so that the

psychobiological approach had an opportunity to gain a respectful place in the study

of schizophrenia.

Sigmund Freud

Whereas the German schools of psychiatry had been interested mainly in the

psychoses, the French schools centered their interest on the study of the

psychoneuroses. Sigmund Freud (1855-1939), himself an Austrian, after spending one

year in Paris at the school of Charcot, felt the influence of the French school of
psychiatry more than of any other. Thus we find that throughout his life he paid only

secondary attention to the study of the psychoses. Freud’s influence on psychiatry as a

whole, however, is of such magnitude and of such a revolutionary nature that even the
field of psychoses had to be totally reviewed in the light of his contributions.

Because of his special interest in the psychoneuroses, Freud was predisposed to

see the psychoses, not as clinical entities completely unrelated psychologically and

etiologically to the psychoneuroses, but, on the contrary, as having the same basic
functions and mechanisms. This point of view was already a fundamental innovation

in a psychiatry that insisted on individualizing nosological entities.

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Discovering Diverse Content Through
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 VI

LIEUT.-GENERAL SIR AYLMER

HUNTER-WESTON, K.C.B., D.S.O.

L
IEUTENANT-GENERAL SIR AYLMER HUNTER-WESTON, K.C.B.,
D.S.O., J.P., and D.L. (Ayrshire), M.P. for North Ayrshire
(1916), was born September 23rd, 1864. He was educated
at Wellington College, Royal Military Academy and Staff
College. He entered the Royal Engineers in 1884 and saw his first
service in 1891, when he took part in the Miranzai Expedition. He
became Captain in the following year. In the Waziristan Expedition of
1894-5 he served as the Commander of the Bengal Sappers and
Miners on Sir W. Lockhart's Staff. He was slightly wounded in this
campaign, and besides getting a medal with clasp, he was
mentioned in despatches and gained his Brevet of Major. During the
Dongola Expedition of 1896 he was attached to Sir Herbert
Kitchener's Headquarter Staff as Special Service Officer, and his work
gained him further mention in despatches, the 4th Class Medjidieh,
the Egyptian Medal with a clasp, and the Queen's Medal. In the
South African War he commanded the Mounted Engineers, Cavalry
Division. Later he became Deputy-Assistant-Adjutant-General to the
Cavalry Division, and subsequently Chief Staff Officer to General
French. Finally he was given independent command of a Mobile
Column. He took part in the operations about Colesburg, in the
Relief of Kimberley, in the Battle of Paardeberg, and the operations
in the Orange Free State, the Transvaal, and Cape Colony. He
commanded five cavalry raids during the advance to Pretoria, cutting
the railway North of Bloemfontein and Kroonstad. He was several
times mentioned in despatches, was promoted Brevet Lieutenant-
Colonel, and received the Queen's medal with seven clasps, and the
D.S.O. Between 1904 and 1908 he was first D.A.A.G. and then
General Staff Officer in the Eastern Command. From 1908 to 1911
he was Chief General Staff Officer of the Scottish Command. From
1911 to 1914 he was Assistant Director of Military Training at the
War Office. Early in 1914 he was promoted Brigadier-General and
appointed to the Command of the 11th Infantry Brigade at
Colchester. At the outbreak of War in August, 1914, he brought this
Brigade out to France, and took part with it in the Great Retreat, in
the subsequent advance, and in all the later fighting in France and
Flanders. He was several times mentioned in despatches and was
promoted Major-General (1914) for distinguished services in the
field. In March, 1915, he was given the command of the 29th
Division and commanded it at the landing at Cape Helles on the
Gallipoli Peninsula as well as in the advance. He was given command
of all British troops at the Southern end of the Gallipoli Peninsula,
and in May, 1915, was promoted Temporary Lieutenant-General to
command VIII Corps. He was praised by Sir Ian Hamilton for "his
invincible self-confidence, untiring energy, and trained ability." Since
March, 1916, he has been in command of the VIII Corps in France.
In this war he has been several times mentioned in despatches, and
has been made a K.C.B., Commandeur of the Legion of Honour, and
Grand Officier of the Belgian Crown.
MAJOR-GENERAL SIR A. G. HUNTER-
WESTON
 VII

LIEUT.-GENERAL SIR CLAUD

WILLIAM JACOB, K.C.B.

L
IEUTENANT-GENERAL SIR CLAUD WILLIAM JACOB, K.C.B., was
born November 21st, 1863. He joined the Worcester
Regiment in 1882, and saw active service in 1890, when he
took part in the Zhob Valley Expedition. In 1893 he became
Captain, and in 1901 Major in the Indian Army.

He was employed on the North-West Frontier of India between

1901 and 1902, in the Waziristan Expedition, in which he won a
Medal and a Clasp. He was promoted Lieutenant-Colonel of the
Indian Army in 1904, and received his Brevet of Colonel in 1908. He
served on the Staff in India as General Staff Officer, 1st Grade,
between 1912 and 1915.

In the latter year he became Brigadier-General (Temporary),

commanding the Dehra Dun Brigade. With his brigade he fought
through the Battle of Neuve Chapelle, when the Bois du Biez was
taken by a magnificent charge and several times cleared, though it
could not be held. The brigade made a brilliant début in the
European War, and their charge was only held up by the line of the
river. He was promoted Major-General in January, 1916, became
temporary Lieutenant-General in May of the same year, and was
promoted Lieutenant-General in June, 1917.
 LIEUT.-GEN. SIR C. W. JACOB

In addition to these promotions for distinguished service in the

present war, he has been mentioned in despatches, the Order of St.
Vladimir (Fourth Class with swords) has been bestowed upon him,
and he was created first C.B. and then K.C.B.
 VIII

MAJOR-GENERAL SIR ARTHUR

EDWARD AVELING HOLLAND, K.C.B.,
M.V.O., D.S.O.

M
AJOR-GENERAL SIR ARTHUR EDWARD AVELING HOLLAND,
C.B., M.V.O., D.S.O., was born April 13th, 1862. He
entered the Royal Artillery in 1880, and saw active service
in Burmah from 1885 to 1889, winning a medal and two
clasps. He was promoted Captain in 1888. Between 1895 and 1898
he was Deputy-Assistant Adjutant-General for the Royal Artillery in
the Madras Presidency, India.

In the South African War (1899-1902) he took part in the

operations in the Transvaal, Orange River Colony and Cape Colony.
He was twice mentioned in despatches and was awarded the D.S.O.,
together with the Queen's Medal and four clasps. He became Major,
Royal Artillery, in 1898. From 1903 to 1905 he acted as Assistant
Military Secretary to the Governor and Commander-in-Chief of Malta,
being given the M.V.O. while he was so serving. At the end of that
period he became Lieutenant-Colonel. He was promoted Colonel in
1910, and in that year became Assistant Military Secretary at the
Headquarters of the Army. In September, 1912, he became
Commandant at the Royal Military Academy, Woolwich, being graded
as a General Staff Officer, 1st Grade. In January, 1913, he was
promoted Temporary Brigadier-General while still at the Royal
Military Academy.
 MAJOR-GENERAL A. E. A. HOLLAND

He left the Academy in September, 1914, when he became

Brigadier-General, Royal Artillery, 8th Division, which, after the first
Battle of Ypres, went to the front to complete Sir Henry Rawlinson's
IV Corps, and served with distinction in the battle near Fromelles in
May, 1915. For distinguished services in this war he was created C.B.
in 1915, and promoted Major-General early in 1916. He received the
honour of Knighthood in January, 1918. The work of artillerists but
rarely finds notice and tends to be assumed; but General Holland
has been mentioned in despatches.
 IX

LIEUT.-GENERAL SIR IVOR MAXSE,

K.C.B., C.V.O., D.S.O.

L
IEUTENANT-GENERAL SIR IVOR MAXSE, K.C.B., C.V.O., D.S.O.,
born 1862, joined the Royal Fusiliers in India in 1882,
exchanged into the Coldstream Guards as a Captain in 1891,
served on the Staff in Scotland and Malta, 1893-4, and
joined the Egyptian Army under Colonel Kitchener for the Soudan
campaigns of 1897, 1898, and 1899. Was Brigade Major on active
service, 1897 to 1898, Chief Staff Officer, Omdurman, 1898, and
commanded the 13th Sudanese Battalion, 1898 to 1899, with the
rank of Bey. Present at battles of Abu Hamed, Atbara, Omdurman,
Elgedid, etc. (two medals, six clasps, D.S.O.).

In the South African war he served as Assistant Adjutant-General

with Mounted Infantry and Colonial Corps in the advance to
Bloemfontein and Pretoria, 1899 to 1900, and subsequently
commanded the South African Constabulary. Present at the battles
of Paardeberg, Driefontein, Sand River, Johannesburg, and Pretoria
(medal, three clasps, C.B., Brevet Lieutenant-Colonel).

Employed on special duty at the War Office, 1901. Subsequently

commanded the 2nd Battalion Coldstream Guards, the Regiment of
Coldstream Guards and the 1st Guards Brigade at Aldershot (C.V.O.).
He proceeded on active service with this brigade, and commanded it
throughout the retreat from Mons to Paris, and in the battles of the
Marne and the Aisne in 1914.
 LIEUT.-GEN. SIR F. IVOR MAXSE

He was then promoted Major-General and appointed to the

command of the 18th Division, which he led to France and
commanded from 1914 to 1917, including the battles of the Somme
and the Ancre and the capture of Thiepval and of Schwaben
Redoubt. Promoted temporary Lieutenant-General and K.C.B.,
January, 1917. Mentioned in despatches eight times, Grand Officer of
the Belgian Crown and Commandeur de la Legion d'Honneur.
 X

LIEUT.-GENERAL SIR THOMAS

LETHBRIDGE NAPIER MORLAND,
K.C.B., K.C.M.G., D.S.O.

L
IEUTENANT-GENERAL (temporary) SIR THOMAS LETHBRIDGE
NAPIER MORLAND, K.C.B., K.C.M.G., D.S.O., was born
August 9th, 1865. He was gazetted Lieutenant to the King's
Royal Rifle Corps in 1884, p.s.c. 1892, and became Captain
in 1893. He was A.D.C. to the Governor and Commander-in-Chief of
Malta from 1895 until he joined the West African Frontier Force in
the spring of 1898. In West Africa he saw extensive service. In the
operations on the Niger and in the Hinterland of Lagos, 1898, he
won a medal and clasp, received his Brevet of Major, and was
mentioned in despatches. He commanded in the Kaduna Expedition
of 1900, and was again mentioned in despatches and received a
further clasp. In the operations in Ashanti in the same year he
received his Brevet of Lieutenant-Colonel and a mention in
despatches and the medal. He commanded the operations against
the Emir of Yola in 1901, and was slightly wounded. In this
campaign he was mentioned in despatches and won a medal with
clasp and the D.S.O. The Bornu Expedition, 1902, which he
commanded, brought him a further mention in despatches, and a
fourth clasp. For his work in the Kano-Sokoto Campaign, 1903, he
was created a Companion of the Order of the Bath, as well as being
again mentioned in despatches. In 1904 he received his Brevet of
Colonel, and from 1905 to 1909 was Inspector-General of the West
African Frontier Force. He returned to England in 1910 to become
Brigadier Commanding 2nd Brigade, Aldershot Command. He
became Major-General in 1913. On the outbreak of this war he was
made Commander of the 2nd London Division, Territorial Force, a
command he held until August 31st, 1914. From September 1st to
October 16th, 1914, he raised and commanded the 14th (Light)
Division. On October 17th, 1914, he took over command of 5th
Division of the Expeditionary Force. With this Division he served until
July, 1915, when he was appointed to the command of an Army
Corps. With this promotion his honours in this war include four
mentions in despatches, and his creation as Knight Commander of
the Order of the Bath, and as Knight Commander of the Order of St.
Michael and St. George.
LIEUT.-GEN. SIR T. L. N. MORLAND
 XI

MAJOR-GENERAL SIR HUGH

MONTAGUE TRENCHARD, K.C.B, D.S.O.

M
AJOR-GENERAL SIR HUGH MONTAGUE TRENCHARD, K.C.B,
D.S.O, Royal Scots Fusiliers, Commandant Central Flying
School since 1914, was born on February 3rd, 1873. He
entered the Royal Scots Fusiliers through the Militia in
1893, and became Captain early in 1900. He had meantime seen
service in South Africa with the Imperial Yeomanry, Bushmen Corps,
and afterwards with the Canadian Scouts. While serving with the
latter he was dangerously wounded, and was awarded Queen's
Medal with three clasps, and the King's medal with two clasps. He
became Brevet-Major in 1902, and served with the West African
Frontier Force between 1903 and 1910. Here he rose to be
Commandant of the North Nigerian Regiment in 1908, having
previously been mentioned in despatches, and having gained the
D.S.O. in 1906; with the West African Frontier Force he won a medal
and three clasps. Towards the end of 1912 he became Instructor,
with the grade of Squadron Commander, to the Central Flying School
of the Royal Flying Corps, being promoted a year later, in September,
1913, to Assistant Commandant.
 MAJOR-GENERAL H. M. TRENCHARD

At the outbreak of war in 1914 he became Commandant

(temporary) of the Military Wing of the Royal Flying Corps. In 1915
he was promoted first Lieutenant-Colonel (January 18th), then
Colonel (June 3rd), with, later, the temporary rank of Brigadier-
General. He held this rank from August 25th, 1915, to March 23rd,
1916, when he became Major-General (temporary). In the June of
1915 he became A.D.C. (extra) to the King, and Brigade Commander
a month later. When the Air Council was formed in January, 1918, he
was appointed Chief of the Air Staff.

Since 1914 Major-General Trenchard has been made a

Commander and a Knight Commander of the Bath, has been
awarded the Order of St. Anne (3rd Class with Swords), and has
received distinguished mention in despatches.
 XII

LIEUT.-GENERAL SIR EDWARD

ARTHUR FANSHAWE, K.C.B.

L
IEUTENANT-GENERAL SIR EDWARD ARTHUR FANSHAWE, K.C.B.,
was born April 4th, 1859. He joined the Royal Artillery at the
time of the Afghan War of 1878, taking part in that
campaign and winning a medal. He again saw service in the
Soudan in 1885, and won a medal with clasp and a bronze star. He
was promoted Captain in 1886, Major in 1896, and Colonel in 1908.
In 1909 he was made (Temporary) Brigadier-General, commanding
the Royal Artillery, 6th Division, Irish Command, and later he
commanded the Royal Artillery in the 5th Division of the same
command. In 1913 he commanded the Royal Artillery in the Wessex
Division of the Southern Command. In September, 1914, he was
promoted Brigadier-General of the Royal Artillery, and held that
position until he became Major-General in June, 1915. He was
promoted Lieutenant-General (Temporary) in July, 1916. Lieutenant-
General Sir Edward Fanshawe has received distinguished mention in
despatches, and, in addition to his promotions, has had bestowed
upon him first the C.B. and later the K.C.B.
LIEUT.-GEN. SIR E. A. FANSHAWE
 The Western Front
Drawings by MUIRHEAD BONE

"They illustrate admirably the daily life of the troops under my command."
—F.M. Sir Douglas Haig, K.T.
In Monthly Parts, Price Parts I.-V. in Volume form, with extra
2/- net. matter, 15/- net.
Parts VI.-X. in Volume form, with
extra matter, 15/- net.

Mr. Muirhead Bone's drawings are reproduced in the following

form, apart from "The Western Front" publication:—

WAR DRAWINGS
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MUNITION DRAWINGS
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WITH THE GRAND FLEET
Size 31½ by 22 inches. Six Plates in portfolio, 20/- net.
"TANKS"
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BRITISH ARTISTS AT THE

FRONT
Continuation of "The Western Front."
 The sequel to the monthly publication illustrated by Mr. Muirhead
Bone will be issued under the title of "British Artists at the Front."

In size, quality of paper and style this publication will retain the
characteristics of its predecessor.

The illustrations will be in colours, and will be provided by

various artists who have been given facilities to make records of the
War.

Part I will be illustrated by Mr. C. R. W. Nevinson, and Part II by

Sir John Lavery, A.R.A.

An illustrated Catalogue referring to the above publications will be sent on

application to "Country Life," Ltd., 20, Tavistock Street, Covent Garden, London,
W.C.2.

Contents of Part I.
I.—HAIG, FIELD-MARSHAL SIR DOUGLAS, K.T., G.C.B., G.C.V.O.,
K.C.I.E., A.D.C.
II.—PLUMER, GENERAL SIR H., C.O., G.C.B., G.C.M.G., G.C.V.O., A.D.C.
III.—RAWLINSON, GENERAL SIR H. S., Bart., G.C.V.O., K.C.B., K.C.V.O.
IV.—GOUGH, GENERAL SIR H. de la POER, K.C.B., K.C.V.O.
V.—ALLENBY, GENERAL SIR E. H., K.C.B.
VI.—HORNE, GENERAL SIR H. S., K.C.B.
VII.—BIRDWOOD, GENERAL SIR W. R., K.C.B., K.C.S.I., K.C.M.G., C.I.E.,
D.S.O.
VIII.—BYNG, GENERAL THE HON. SIR J. H. G., K.C.B, K.C.M.G., M.V.O.
IX.—CONGREVE, LIEUT.-GEN. SIR W. N., V.C., K.C.B., M.V.O.
 X.—HALDANE, LIEUT.-GEN. SIR J. A. L., K.C.B., D.S.O.
XI.—WATTS, LIEUT.-GEN. SIR H. E., K.C.M.G., C.M.G.
XII.—SMUTS, LIEUT.-GEN. The Rt. Hon. JAN C., P.C., K.C., M.L.A.

Large Reproductions of some of these Portraits may be obtained, price 2/6 each.

Uniform with this publication.

Admirals of the British Navy

Portraits by FRANCIS DODD
EACH PART 5/- NET.

Contents of Part I.
INTRODUCTION.
I.—JELLICOE, ADMIRAL LORD, G.C.B., O.M., G.C.V.O.
II.—BURNEY, ADMIRAL SIR CECIL, G.C.M.G., K.C.B., D.S.O.
III.—MADDEN, ADMIRAL SIR C. E., K.C.B., K.C.M.G., M.V.O.
IV.—PHILLIMORE, REAR-ADMIRAL SIR R. F., C.B., M.V.O.
V.—BACON, VICE-ADMIRAL SIR R. H. S., K.C.B., K.C.V.O., D.S.O.
VI.— DE ROEBECK, VICE-ADMIRAL SIR J. M., K.C.B.
VII.—NAPIER, VICE-ADMIRAL T. D. W., C.B., M.V.O.
VIII.—BROCK, VICE-ADMIRAL SIR OSMOND de B., K.C.V.O., C.B., C.M.G.
IX.—HALSEY, REAR-ADMIRAL LIONEL, C.B., C.M.G.
X.—PACKENHAM, VICE-ADMIRAL SIR W. C., K.C.B., K.C.V.O.
XI.—PAINE, COMMODORE GODFREY M., C.B., M.V.O.
 XII.—TYRWHITT, REAR-ADMIRAL SIR R. Y., K.C.B., D.S.O.

Contents of Part II.

INTRODUCTION.
I.—BEATTY, ADMIRAL SIR DAVID, G.C.B., G.C.V.O., D.S.O.
II.—JACKSON, ADMIRAL, SIR H. B., G.C.B., K.C.V.O., F.R.S.
III.—COLVILLE, ADMIRAL THE HON. SIR S. C. J., G.C.V.O., K.C.B.
IV.—BROCK, ADMIRAL SIR F. E. E., K.C.M.G., C.B.
V.—GRANT, REAR-ADMIRAL H. S., C.B.
VI.—TUDOR, VICE-ADMIRAL SIR F. C. T., K.C.M.G., C.B.
VII.—CALLAGHAN, ADMIRAL OF THE FLEET SIR G. A., G.C.B., G.C.V.O.
VIII.—LEVESON, REAR-ADMIRAL A. C., C.B.
IX.—KEYES, REAR-ADMIRAL ROGER J. B., C.B., C.M.G., M.V.O., D.S.O.
X.—EVAN-THOMAS, VICE-ADMIRAL SIR H., K.C.B., M.V.O.
XI.—BRUCE, REAR ADMIRAL H. H., C.B., M.V.O.
XII.—ALEXANDER-SINCLAIR, REAR-ADMIRAL E. S., C.B., M.V.O.

Hudson & Kearns, Ltd., Printers, Hatfield Street, London, S.E. 1.

Transcriber's Notes:

Punctuation and spelling standardized when a

predominant preference was found in this book;
otherwise unchanged. Simple typographical errors
remedied; most retained.

In Advertisements, Black Letter honorific

abbreviations are shown here in boldface.
 When originally published, the Tables of
Content were on the back covers. In this eBook,
each has been moved to the beginning of the Part
it references.
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