Schizophrenia is typically a catastrophic illness that begins in adolescence or early adulthood. Although severe psychotic disorders have been recognized for centuries, as evidenced by descriptions in medical writings and literary portrayals, the classification of psychotic disorders into specific forms such as manic-depressive illness or schizophrenia only occurred approximately one hundred years ago.

Because the symptoms of schizophrenia often produce severe incapacity, the illness was originally called "dementia praecox" by Emil Kraepelin. Schizophrenia was initially defined in the late nineteenth century by him and a team of psychiatrists who worked with him, which also included Alois Alzheimer. Schizophrenia, or dementia praecox, was originally distinguished from dementia in the elderly (later named Alzheimer's disease) because it occurred in relatively young people rather than older people.

 It was also distinguished from manic-depressive illness on the basis of how long symptoms lasted, with dementia praecox tending to be more persistent while manic-depressive illness was intermittent and patients sometimes got better on their own. A few years after Kraepelin's original definition, Eugen Bleuler suggested renaming this disorder "schizophrenia," which means "fragmented mind."

Schizophrenia is characterized by a mixture of signs and symptoms, no one of which is necessarily present. In this sense, it differs from many other psychiatric disorders, which are typically defined by a single prominent feature. Depression, for example, is characterized by dysphoric mood, mania by elevated mood, and panic disorder by the presence of panic attacks. The absence of a single defining feature for schizophrenia sometimes makes this disease difficult for people to understand.

Emil Kraepelin: Course and Outcome

Kraepelin's conceptualization stressed the aspects of severity and chronicity. The syndrome that he defined, dementia praecox, tended to begin relatively early in life ("praecox") and to produce a pervasive and persistent impairment in many different aspects of cognitive and behavioral function ("dementia"). While Kraepelin repeatedly stressed the diversity of signs and symptoms occurring in dementia praecox, and suggested that abnormalities in volition and affect were especially important, he found a chronic course and a poor outcome to be the characteristic defining features. His concept evolved over time, however, as he received feedback from other experts and his own ongoing clinical experience. He was a devoted empiricist with two years of training in Wundt's laboratory in Leipzig early in his career. Over his long career he was able to follow up a large sample of patients, and he observed that 12.5% of these recovered. Consequently, he later agreed with Bleuler that some patients with dementia praecox could recover.

Kraepelin's original formulation was rapidly complemented by the work of Bleuler, who suggested that the term "dementia praecox" should be superseded by "the group of schizophrenias." Bleuler emphasized a different aspect of this large syndrome. While Kraepelin thought about course and outcome, Bleuler pondered the nature of the characteristic symptoms. He was particularly interested in trying to identify which among the multiplicity of symptoms could be considered to be most basic or fundamental.

For Bleuler, the most important symptom was a fragmentation in the formulation and expression of thought, which he interpreted in the light of the associational psychology prevailing at the time and referred to as "loosening of associations." He renamed the disorder "schizophrenia" to emphasize the fragmenting of associations as the fundamental feature of this disorder.

The views of a third European psychiatrist, Kurt Schneider, have also been very influential in conceptualizations of schizophrenia. Like Bleuler, Schneider was interested in identifying the main symptoms of schizophrenia. He developed a description of a set of "First Rank Symptoms" (FRS), which he believed to be specific to schizophrenia and diagnostic of it. Schneiderian First Rank Symtpoms are specific types of delusions and hallucinations, such as thought insertion, thought broadcasting, delusions of control, or voices commenting. They tend to be tied together by the common thread that the patients perceive themselves as losing control of their thoughts, feelings, and bodies. Schneider's emphasis on these symptoms was derived from clinical observations and his beliefs about the origin of the disease.

Conclusion

These three ways of thinking about schizophrenia--the Kraepelinian, the Bleulerian, and the Schneiderian--co-exist in contemporary thinking about the nature of schizophrenia. Individual clinicians tend to vary in the value and emphasis that they place on these three perspectives, sometimes leading to clinical debates as to whether a patient "really has schizophrenia." Some clinicians base their diagnosis primarily on a Kraepelinian emphasis on chronicity and poor outcome, while others stress Bleulerian negative symptoms and thought disorder, and yet others insist on the presence of florid and prominent psychotic symptoms. These differing perspectives reflect a very real debate about the basic essence of schizophrenia. This debate is not likely to reach closure until the disorder can be defined in terms of its pathophysiology and etiology.

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