Paul Eugen Bleuler ( BLOY-lər; Swiss Standard German: [ˈɔʏɡeːn ˈblɔʏlər, ˈɔʏɡn̩]; 30 April 1857 – 15 July 1939) was a Swiss psychiatrist and eugenicist most notable for his influence on modern concepts of mental illness. He coined several psychiatric terms including schizophrenia, schizoid, autism, depth psychology and what Sigmund Freud called "Bleuler's happily chosen term 'ambivalence'". Bleuler remains a controversial figure in psychiatric history for his racist and ableist beliefs, as well as his implementation of eugenic practises in psychiatry based on these beliefs, most notably at the Burghölzli clinic in Zurich.
Bleuler was born in Zollikon, a town near Zürich in Switzerland, to Johann Rudolf Bleuler (1823–1898), a wealthy farmer, and Pauline Bleuler-Bleuler (1829–1898). He married Hedwig Bleuler-Waser, one of the first women to receive her doctorate from the University of Zurich.
Bleuler studied medicine in Zürich. He trained for his psychiatric residency at Waldau Hospital under Gottlieb Burckhardt, a Swiss psychiatrist, from 1881 to 1884. He left his job in 1884 and spent one year on medical study trips with Jean-Martin Charcot, a French neurologist in Paris, Bernhard von Gudden, a German psychiatrist in Munich, and to London. After these trips, he returned to Zürich to briefly work as assistant to Auguste Forel while completing his psychiatric residency at the Burghölzli, a university hospital.
Bleuler became the director of a psychiatric clinic in Rheinau, a hospital located in an old monastery on an island in the Rhine. At the time, the clinic was known for being functionally backward and largely ineffective. Because of this, Bleuler set about improving conditions for the patients residing there.
In the year 1898, Bleuler returned to the Burghölzli and became a psychiatry professor at Burghölzli, the same university hospital at which he completed his residency. He was also appointed director of the mental asylum in Rheinau. He served as the director from the years 1898 to 1927. While working at this asylum, Bleuler cared for long-term psychiatric patients. He also implemented both psychoanalytic treatment and research, and was influenced by Sigmund Freud.
During his time as the director of psychiatry at Burghölzli, Bleuler made great contributions to the field of psychiatry and psychology that made him known today. Given these findings, Bleuler has been described as one of the most influential Swiss psychiatrists.
Relationship with Freud and Jung
Following his interest in hypnotism, especially in its "introspective" variant, Bleuler became interested in Sigmund Freud's work. He favorably reviewed Josef Breuer and Freud's Studies on Hysteria.
Like Freud, Bleuler believed that complex mental processes could be unconscious. He encouraged his staff at the Burghölzli to study unconscious and psychotic mental phenomena. Influenced by Bleuler, Carl Jung and Franz Riklin used word association tests to integrate Freud's theory of repression with empirical psychological findings. As a series of letters demonstrates, Bleuler performed a self-analysis with Freud, beginning in 1905. Bleuler laid the foundation for a less fatalistic view of the course and outcome of psychotic disorders along with C. G. Jung, who further used Bleuler's theory of ambivalence and association experiments to diagnose neurotic illnesses.
Bleuler found Freud's movement to be overly dogmatic and resigned from the International Psychoanalytic Association in 1911, writing to Freud that "this 'all or nothing' is in my opinion necessary for religious communities and useful for political parties...but for science I consider it harmful".
Bleuler remained interested in Freud's work, citing him favorably, for example, in his often reprinted Textbook of Psychiatry (1916). He also supported the nomination of Freud for the Nobel Prize in the late twenties.
Dementia Praecox, or the Group of Schizophrenias
Bleuler introduced the term "schizophrenia" in a Berlin lecture on 24 April 1908. However, he and his colleagues had been using the term in Zurich to replace Emil Kraepelin's term dementia praecox since 1907. He revised and expanded his schizophrenia concept in his seminal study of 1911, Dementia Praecox, oder Gruppe der Schizophrenien (Dementia Praecox, or Group of Schizophrenias). This was translated into English in 1950 (by Joseph Zinkin).
Bleuler distinguished between positive and negative symptoms of schizophrenia. Positive symptoms include symptoms not found in unaffected people, such as hallucinations or delusions. Negative symptoms describe the absence of typical experiences such as social withdrawal or lack of pleasure. Bleuler also distinguished between basic and accessory symptoms as well as primary and secondary symptoms. Basic symptoms are those that are present in every case of schizophrenia, whereas accessory symptoms vary depending on the patient. Bleuler defined primary symptoms as those that are directly related to neurobiological processes. He defined secondary symptoms as behavioral reactions to primary symptoms. Differentiating these symptoms contributed to an increased understanding of schizophrenia in general.
Like Kraepelin, Bleuler argued that dementia praecox, or "the schizophrenias", was a physical disease process characterized by exacerbations and remissions. He argued that no one was ever completely "cured" of schizophrenia; there was always some sort of lasting cognitive weakness or defect that was manifest in behavior. Unlike Kraepelin, Bleuler believed that the overall prognosis was not uniformly grim. He believed "dementia" was a secondary symptom not directly caused by the underlying biological process. There were three other "fundamental symptoms" that included deficits in associations, affectivity, and ambivalence. He believed the biological disease was much more prevalent in the population due to its "simple" and "latent" forms.
Bleuler's changes to Kraepelin's dementia praecox were accepted by countries such as Switzerland and Britain. However, some countries, such as Germany, did not accept these changes at first. Bleuler's concept of schizophrenia was pushed aside due to its similarities to Kraepelin's dementia praecox. It was only widely accepted after Kraepelin's disease classification did not have direct evidence nor was it directly expressed in his patients.
In 1911, Bleuler wrote, "When the disease process flares up, it is more correct, in my view, to talk in terms of deteriorating attacks, rather than its recurrence. Of course the term recurrence is more comforting to a patient and his relatives than the notion of progressively deteriorating attacks". The eugenic sterilization of persons diagnosed with (and viewed as predisposed to) schizophrenia was advocated by Bleuler. He argued that racial deterioration would result from the propagation of "mental and physical cripples." In his Textbook of Psychiatry, Bleuler states,
The more severely burdened should not propagate themselves...If we do nothing but make mental and physical cripples capable of propagating themselves, and the healthy stocks have to limit the number of their children because so much has to be done for the maintenance of others, if natural selection is generally suppressed, then unless we will get new measures our race must rapidly deteriorate.