The Schizophrenia Concept: Timeline Highlights

Historical highlights of the lumper-splitter debate on schizophrenia

Eugen Bleuler. Wikimedia Commons

While there are disagreements about how to understand the concept of schizophrenia, it is generally agreed that schizophrenia is the prototypical mental disorder. What that means is that patients diagnosed with schizophrenia experience significant thought and mood variations and, as a result, have different degrees of psychosocial disability. At one end of the spectrum, the minority opinion is that schizophrenia is a social construct, a product of cultural norms and expectations imposed on a non-conforming individual.

The majority opinion however, hold by most mental health experts, is that schizophrenia is a mental disorder with biological roots; as such, conceptually similar to other medical disorders. However, experts disagree with regards to schizophrenia being an unitary concept (the lumpers) as opposed to different disorders that are just conveniently grouped under one category (splitters).

In his article we will discuss the conceptual development and highlights of the mainstream, majority view of schizophrenia. The discussion of the anti-psychiatry view of schizophrenia will be the subject of a different article.

Schizophrenia or schizophrenias?

Are schizophrenia disorders part of a homogeneous category (different presentations of the same thing - ONE schizophrenia) or a mixture of different categories with only superficial commonalities (different presentations of different things - schizophrenias)?

To answer this question we will review the historical development of the schizophrenia concept.

1852, Rouen, France: Bénédict Morel, a French physician and the director of the mental asylum at Saint-Yon in Rouen, published his first volume of Études cliniques (1852; “Clinical Studies”), where for the first time in the history of psychiatry, the term démence précoce (premature dementia) is used to describe the clinical picture of a group of young patients with thought disorganization and an overall disorder of will.

Back in Morel’s time however the concept of dementia had a different meaning than today. First, it did not imply a chronic and irreversible course; second; it did not automatically mean that cognitive problems (e.g. difficulties in the areas of memory, attention, concentration, problem solving) were also present. In fact Morel’s démence précoce diagnosis appears to not overlap well with Kraeplin dementia praecox, the immediate predecessor of the diagnosis of schizophrenia.

1891, Prague, Austro-Hungarian Empire: first recorded use of the term dementia praecox by Arnold Pick, a Czech neurologist and psychiatrist who reports on a patient with a clinical presentation consistent with what would now be diagnosed as a psychotic disorder.

1893, Heidelberg, Germany: Emil Kraepelin advances psychiatric classification. Kraepelin moves from grouping mental disorders based on superficial similarities between major symptoms to grouping mental disorders based on their course over time. From a course perspective he distinguishes dementia praecox, with its chronic and persistent course from manic depression, with a cyclical course.

Of note, Kraepelin initially also distinguished dementia praecox (the official predecessor of schizophrenia) from dementia paranoides and catatonia. Kraepelin started of as a splitter, in that he supported the view that those were different disorders. Later on however, Kraepelin changes to a lumper, in that he groups the different presentations as “clinical forms” of essentially one disorder: dementia praecox, a term w

1907, Zürich, Switzerland: Eugen Bleuler coins the term schizophrenia and describes the distinct subtypes of the disorder, stating that schizophrenia 'is not a disease in the strict sense, but appears to be a group of diseases. Therefore, we should speak of schizophrenias in the plural'. Definitely, a splitter.

20th century to recent past: There are four main categories of symptoms that most experts agree occur in schizophrenia: positive symptoms, negative symptoms, cognitive symptoms, and affective symptoms. Positive versus negative schizophrenia and deficit and non-deficit schizophrenia have been proposes as different schizophrenia types. The ”lumpers” propose that all these symptoms or types, despite differences in presentation, course over time, and response to medications, are in fact different forms of one common underlying abnormality that is characteristic (but yet to be determined) of schizophrenia. On the other hand, the “splitters” are of the opinion that different pathological processes underline the different clinical presentations; thus, schizophrenias as opposed to schizophrenia better describe the realities of differences in presentation, course, prognosis and response to treatment for different groups of patients. The DSM III to IV R classification systems were differentiated between five different types of schizophrenia: paranoid, disorganized, catatonic, residual, and undifferentiated – more of  a splinter view of schizophrenia.

Which brings us to now:

The current DSM V dumped all schizophrenia subtypes as essentially uninformative with regards to treatment recommendations or prediction of treatment response – more of a lumper approach. However this does not appear to be the final answer to the splitting-lumping debate. With increased knowledge about genetic differences in the genetic background and advances in patient-centered medicine it is possible that the pendulum might swing back to a splitting perspective in the future.

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