Gerd Huber and Gisela Gross: The Development of the Psychopathology in Germany in the Last Decades (20th century) with an Introduction by Carlos R. Hojaij
Carlos Hojaij´s reply to Edward Shorter and Hector Warnes
“When I was a child, walking down a mountain at Céret, I saw a strange man named by everybody as a ‘fool’. I was intrigued -as all others- by his oddity. In certain cultural ambient, the Vallespir, one was gripped by anxiety and fear… This is the image today I refer to schizophrenia, this image all imbued with enigma, whimsical and fantastic, which for all my life I am trying to understand.”
Henri Ey
A few weeks before the publication of "La Notion de Schizophrenie, Séminaire de Thuir” (Ey 1977), Henri Ey died of a heart attack. It was a big loss, personally and for the world psychiatry. Once more, because he wrote in French, most of his exceptional work became oblivious to English-speaking countries. These comments are not intended to go into the several contributions Ey offered to psychiatry. But it is relevant to say his talks and publications on schizophrenia came from decades of vivid experience, developing his own casuistic. It is estimated he presented 500 schizophrenics during clinical meetings at the Sainte Anne Hospital in Paris from 1932 to 1970. Throughout his psychiatric career Ey remained loyal to the child’s pure, intuitive apprehension of schizophrenics. His hypothesis and theories came after the intuition.
In reality, Ey was observing a schizophrenic, not schizophrenia.
The romantic schizophrenics’ view disappeared, “tsunamised" by the horrendous DSM. The strange, odd man doesn't intrigue anymore; he doesn't inspire fantasies anymore; the enigma - also Wyrsch’s (1957) expression - has been reduced to few boxes to be ticked by illiterate new psychiatrists, whose knowledge is limited to the information provided by psychiatry’s single worldwide best seller.
Nowadays, schizophrenia is a boring matter. Since psychiatry without schizophrenia loses its most charming object, nowadays psychiatry, too, is boring.
It is now 42 years since I presented the thesis “Autism as a mode of existence” (Hojaij 1978). The paper was a penetration into the human reality we designate as autism, considered as a schizophrenic expression: autism as mode-of-being-in-the-world. The autistic person is portrayed as being marginal to the common existence, experiencing the incapacity of being with others and having affective participation. However, when stimulated to talk and permitted to be listened to, the schizophrenic person expresses that he is living without living, existing without existing - a marginal, or ex-travagant (Binswanger 1972).
After developing a deeper study, in 1987 I defended my doctoral thesis on “Compreensão no Esquizofrênico” (“Understanding in the Schizophrenic”) (Hojaij 1987). The purpose was again to penetrate the schizophrenic world to understand how the schizophrenic understands himself and how he understands (or not) others and the world. The emphasis was in the understanding’s process itself (Dilthey 1978a,b). The process had been broken and distorted at certain point in life, a moment that could be identified by the schizophrenic (a broken personality characterizing the psychic process of Jaspers) and in a way that I could designate as a point-of-no-return. I was able to closely (weekly) follow up a small group of patients for several years, who were treated by either major tranquillizers, or neuroleptics or anti-psychotics with psychotherapy. During this time favorable psychological progress in the schizophrenic was noticed. However, the disease (schizophrenia) continued affecting: a. intuition, a structural modification, the experience of losing the teleological sense, being then moved by causality law restricting a whole apprehension of the situation; b. transposition capability (to be in another’s situation, according to Conrad [1963]), the empathy; and c. personality which, from the point of no-return, follows its original development, different from the first phase. It also became clear that hallucinations and delusions, although dramatic phenomena, are just secondary manifestations in the life of a schizophrenic.
I take the liberty of bringing together my replies to Hector Warnes and Edward Shorter, for one points out the importance of a historical perspective (Warnes 2019) and the other (although an expert in the history of psychiatry, or maybe because of having this expertise) declares schizophrenia maybe just "a prodrome of different diseases” or is a “concept disaggregated and sectioned into its components parts” (Shorter 2019).
If, after more than 130 years, psychiatric clinicians and researchers from all over the world are still having trouble identifying, describing, distinguishing, categorizing and treating schizophrenia, what is the problem or problems?
Maybe the reason can be found in Shorter’s comment: “…as the schizophrenia concept is disaggregated and sectioned into its component parts.” I would say the current vision and research on schizophrenia suffer this disaggregation or dissociation. Bleuler’s (1960) concept of schizophrenia is manifest in relation to its study: the research is schizophrenic. In an attempt to elucidate the sacred (psychiatric) illness's enigma, everyone takes a piece and follows its own route ignoring the clinic, essential to know who is affected, what is there, the treatment method to be used and how to correlate with other data. Several decades ago the term “schizoaffective" was created to solve the dilemma: schizophrenia or manic-depression? For a few decades genetic studies were talking about genes involved in schizophrenia; for several decades imaging studies were making correlations of images with schizophrenia; decades ago the term anti-psychotic was created to automatically connect a drug to schizophrenia; for decades in some classification schizophrenia was dumped into the same box of “other psychosis”; for decades a chronic schizophrenic was newly identified as a mentally disabled or chronic melancholic, a personality disorder, etc. However, on the other hand, for several decades the term “schizophreniform” was used to designate a clinical picture resembling schizophrenia - a schizophrenia syndrome. I consider the term “schizophreniform" as the intention to preserve authentic schizophrenia (whatever schizophrenia is). It is supposed that a schizophreniform illness is much more frequent than schizophrenia. In terms of research, I understand we are still living in a primitive era when the major task is to identify all possible illnesses similar to schizophrenia and, as Schneider thought, make a diagnosis by exclusion to then proceed with a limited group of patients.
Even after 130 years or so, the schizophrenia enigma still persists. In order the evolve to a possible resolution, the real struggle of so many researchers, mainly those who dedicated years seeing, examining, treating and reflecting over a huge casuistic, cannot be disregarded. Under my point of view, personal casuistic and casuistic of well-founded psychiatric services cannot be replaced by the “democratic assembly” of everybody to establish what schizophrenia is and how to treat it. That is to say: the current schizophrenia's concept needs to be integrated in a clinical historical perspective of the phenomenon schizophrenia, from Kraepelin to cosmos.
If the clinical concept of schizophrenia as a neurodevelopment illness is accepted and the main features related to personality's disintegration as an essentially human disease, it could be valid to hypothesize that schizophrenia is linked to brain areas distinguishing the homo sapiens. Conrad (1963) considered that man’s spiritual nucleus would be the central point of the schizophrenic process: “We understand that is obvious that the disease affects the main area that distinguishes man from animal: the self and the reflexive capacity of transposition… It should be a functional change in primitive parts of cerebral organization differentiating from the brain of most developed primates.” Conrad continues, “the result of our analysis stimulates a continued search of the process according to physiopathological bases.” In the same sense, neuroimaging consciousness's studies (Edelman and Tononi 2000) as an extension of clinical psychopathological investigation could bring fruitful results in terms of etiology and development of this psychiatric anomaly. Consequently, possible intervention through sub-atomic particles may provide efficacy to treatment, until genetics has stronger voice.
References:
Binswanger L. Tres Formas de la existencia frustrada. Buenos Aires, Amorrortu Editores, 1972.
Bleuler E. Demencia Precoz. El Grupo de las Esquizofrenias. Buenos Aires, Paidós, 1960.
Conrad K. La Esquizofrenia Incipiente. Madrid, Alhambra, 1963.
Dilthey W. Psicologia y Teoria del Conocimiento. México, Fondo de Cultura Ecónomica. 1978a.
Dilthey W. El Mundo Histórico. México, Fondo de Cultura Ecónomica. 1978b.
Edelman GM, Tononi G. A Universe of Consciousness. How Matter Becomes Imagination. New York, Basic Books, 2000.
Ey H. La Notion de Schizophrenie. Séminaire de Thuir, Février-Juin 75. Desclée De Brouwer, 1977.
Hojaij CR. Autismo como forma de existência. Unpublished thesis, Master in Social
Psychology. Catholic University of São Paulo, São Paulo, 1978, pp. 63.
Hojaij CR. Compreensão no Esquizofrênico. Unpublished doctoral thesis. University of São Paulo, São Paulo; 1987, pp. 212.
Jaspers K. Delírio Celotípico, contribuición al problema: Desarrollo de una Personalidad o Processo? In: Escritos Psicopatológicos. Madrid, Gredos, 1977.
Shorter E. Comment. Gerd Huber and Gisela Gross: The Development of the Psychopathology in Germany in the Last Decades (20th century) with an Introduction by Carlos R. Hojaij. inhn.org.perspective. September 19, 2019.
Warnes H. Comments. Gerd Huber and Gisela Gross: The Development of the Psychopathology in Germany in the Last Decades (20th century) with an Introduction by Carlos R. Hojaij. inhn.org.perspective. October 3, 2019.
Wyrsch J. La Persona del Esquizofrenico. In: Symposium sobre Esquizofrenia. Madrid, Consejo Superior de Investigaciones Científicas, Departamento de Medicina y Psicosomática. 1957.
July 16, 2020