Some Considerations Bearing on the Diagnosis and Treatment of Dementia Præcox1

With regard to the diagnosis of præcox I feel that we are on very uncertain ground. Kraepelin gave a masterly grouping and description of symptoms which, on the whole, has an unfavorable course and which we have agreed in a general sort of way to designate as dementia præcox. No one as yet, however, has been able to sufficiently define the underlying factor or factors which bind these symptoms together into a diagnostic unit. No one has been able to define the fundamental processes, the mechanisms which are at work, and of which they are the expression. Bleuler has more definitely made an attempt at a grouping of the symptoms along certain definite lines which indicate their relationship, but the whole matter is still, I believe, very far from our understanding and the problem will not be solved, obviously, until all of the facts, at all of the several levels, vegetative, neurological, psychic and social, can be brought together in a unifying synthesis. At present the facts are best resumed in a formulation at the psychological or better at the psycho-social level. In fact almost the only thing about which it seems to me we can come to agreement is that dementia praecox is a regression psychosis and that its general tendency is malignant. Regression, however, is such an all-comprehensive term, it includes so many symptoms that do not even suggest malignancy or præcox, that to have said that dementia præcox is a regression psychosis is to have said very little. If regression is the only fundamental character, When does it become præcox? and if it is not the only fundamental mechanism at work, What are the other mechanisms?

I am going to discuss briefly a suggestion as to the direction in which a solution may be sought. In the first place, I feel that regression is the fundamental, underlying mechanism which is responsible for the manifestations. Sticking entirely to the psychological level it seems to me that the whole picture of præcox can be adequately resumed under