On the origins of the concept of ‘latent schizophrenia’ in Russian psychiatry

Material and methods

The basis of this article is work conducted in the framework of the research project ‘German–Russian relations in the fields of medicine, chemistry and pharmacy in the 19th century’, set up by the Saxon Academy of Sciences (Germany) and the Karl-Sudhoff Institute of the History of Medicine at the University of Leipzig. It involved searching for the relevant primary literature in influential neuropsychiatry journals of the late nineteenth and early twentieth centuries. The relevant secondary literature was also taken into account. For bibliographical data, a bio-bibliographical lexicon compiled within that project (Engmann, 2018) was used.

Historical background

In the 1970s and 1980s, compulsory treatment of political dissidents in psychiatric clinics of the Soviet Union was gradually revealed, beginning with a few reports from those affected. Among others, one influential work was the investigative book Punitive Medicine by Aleksandr Pinkhosovich Podrabinek (b. 1953). As regards the justification for the authorities’ compulsory psychiatric treatment, he brought up concepts of borderline conditions, i.e. slow and weak forms of schizophrenia which allegedly make the sufferer prone to criminal acts (Podrabinek, 1980: 141; see also Cohen, 1989: 42). But what are the roots of that concept, which at least in some cases also lead to political abuse?

More recent Soviet, then Russian publications (Smulevich, 1989; Pyatnitskiy, 2017, respectively) point out that, with regard to latent schizophrenia, Soviet research activities in the 1930s and again in the 1960s mainly refer to Bleuler’s concept of latent schizophrenia. According to them, Soviet psychiatrists such as Lev Markovich Rozenstein (1884–1934) refined Bleuler’s concept. This article scrutinizes the question of whether there is evidence of early concepts of latent schizophrenia-like disorders in pre-Soviet psychiatric research. It is noteworthy that the term ‘schizophrenia’ does indeed go back to the Swiss psychiatrist Eugen Bleuler (1857–1939). His works were based on the previous concept of ‘Dementia praecox’ attributed to the German psychiatrist Emil Kraepelin (1856–1926), whose works were also well known in the Russian Empire (Engmann and Steinberg, 2017a). The third edition of Bleuler’s textbook of psychiatry in 1920, first issued in 1916, was translated into Russian language in the same year by a publishing house in Berlin (Bleuler, 1920). In this early edition, the concept of latent schizophrenia was still in its early stages of development. It was still subordinated under schizophrenia simplex. Here, Bleuler referred to cases in which the disease was unnoticeable (‘nezamechennyi’), which was translated into Russian as hidden (‘skrytaya’) schizophrenia (Bleuler, 1920). In the following editions of his textbook, Bleuler further developed the diagnostic category ‘latent schizophrenia’: according to him, it was a form of the many schizophrenias that never become clinically manifest. Behavioural traits include growing inability to do one’s job, a gradual lowering of social status, more or less querimonious behaviour, insisting on all kind of rights while neglecting duties, alcoholism, and so on (Bleuler, 1949: 310).

Is there evidence of a specifically Russian route to latent schizophrenia?

Official Russian classifications like those from 1886 (St Petersburg) and 1892 (Moscow) did not list any latent schizophrenia-like disorders. Moreover, it is remarkable that ‘psychic health’ is an item listed in both classifications (Korsakov, 1913/1954: 167). On the other hand, the term ‘ideophrenia’ introduced by Victor Khrisanfovich Kandinskii (also written Kandinsky) (1849–89) in 1882 is not mentioned, although it could be regarded as a precursor of both Kraepelin’s and Bleuler’s concepts of Dementia praecox and schizophrenia, respectively (Engmann and Steinberg, 2017b). Kandinskii distinguished an acute hallucinatory type from a catatonic and chronic one, but did not describe a hidden or latent form of ‘ideophrenia’ (Kandinskii, 1890). A decade after Kandinskii’s classification, Sergei Sergeievich Korsakov (also Korsakoff) (1854–1900) suggested the term ‘dysnoia dementica’ for a disease with delusions, hallucinations, stupor and dementia. At the Fourth Congress of Russian Physicians in memory of N.I. Pirogov in 1891, Korsakov introduced the term ‘dysnoia abortiva’ as a special form, comprising disorders of attention, concentration, and ‘feelings of indefinite dread’ (Korsakov, 1893/1954: 182).

Russian psychiatry was also influenced both by degeneration theories and the effect of inheritance of personal traits, especially with regard to the development of psychic diseases. An example is the work of the presumably Russian-born Ernst Erikson (b. 1867), who wrote his dissertation in Vladimir Bekhterev’s clinic in St Petersburg. Erikson was interested in the relationship between anthropology and psyche, and he postulated the inheritance of ‘hysteria’ among the Jewish population in the Tsardom of Poland; one consequence of this was that Jewish men were even less willing to join the Russian military service than their Polish fellow citizens, who were already much less willing than the Russians. In his quest for reasons, Erikson (1908) completely neglected discrimination and recurring pogroms as possible triggers.

The decade before World War I was a period of social upheaval in the Russian Empire, which reached its climax in the 1905 revolution. The Russian psychiatrist Fedor Egorovich Rybakov (1868–1920), who worked at the University of Moscow, initiated a commission at the Moscow Society of Neuropathologists and Psychiatrists with the aim of investigating the influence of the turmoil on the psychic health of the population (Gadzyatskyi, 1908). The question of possible psychic origins was also a subject of scrutiny. Rybakov published several articles on this topic in the Russian medical journal Vrach (in English, The Physician). He drew several conclusions. One was that the psychically ill could be initiators of political upheavals, i.e. such people have an inclination to depressive delusions and hints of inherited psychic disorders. Consequently, psychic disorders are biased by political events. In a situation of upheaval, passive individuals are more prone to develop a psychic disorder than active participants are (Rybakov, 1905, 1906a, 1906b, 1907; see also Sklyar, 1906a, 1906b). In this sense, both Aleksandr Sergeevich Sholomovich (d. 1932) at the Kazan mental hospital and Lidiya Stepanovna Pavlovskaya (b. 1872), who worked in St Petersburg, argued that ‘weak and passive personalities’ (Sholomovich, 1907) and people with a ‘pathological predisposition’ more often get mentally sick. Those who take part actively in the upheaval have a small burden of sickness (Pavlovskaya quoted by Gadzyatskyi, 1908: 92). Healthy people have higher resilience than the mentally ill to bitterness and anxiety connected with such turbulence (Gadzyatskyi, 1908: 91). Fedor Christoforovich Gadzyatskyi (b. 1860), a psychiatrist at the Riga Military Hospital, concluded in his review article that there is no special form of a ‘revolutionary psychosis’ (p. 93). The article pointed out a certain predisposition as a risk factor in the development of psychic disease due to different critical life events; people without such inclinations remain unaffected. Clearly, this statement already resembles modern concepts of resilience or the stress-diathesis model.

In his textbook of psychic diseases, Vladimir Petrovich Serbskii (also Serbsky) (1858–1917), an important Russian psychiatrist, follows Kraepelin’s definition of ‘dementia praecox’ (Serbskii, 1911: 40). It seems that Serbskii did not reflect on a latent course, something also revealed by the term ‘dementia’ itself, which determines the worst outcome of the course of the disease. In contrast, Boris Savel’evich Greidenberg (1857–1923), who worked at the University of Charkow (Kharkiv), avoided any circumscribed diagnostic entities. In his textbook on forensic psychiatry, he referred rather to symptom complexes. Hints of a hidden schizophrenia-like disease are not obvious (Greidenberg, 1915).

The influence of social circumstances on psychic disorders and abnormal behaviour also played a role in the Russian concepts of psychiatric diagnoses. This was mainly advocated by the influential neurologist and psychiatrist Vladimir Mikhailovich Bekhterev ¹ (1857–1927). He claimed that, since human acts are a consequence of experience and environmental circumstances, personality cannot be studied if the environment is neglected. In this sense, Bekhterev considered prisons as ‘gloomy remnants from an old barbarian world’ (Bechterew, 1914: 53) and suggested treating offenders in hospital-like facilities rather than prisons. As regards decreasing social deviance, he wished for ‘happy days without lords and servants on earth’ (p. 51). Bekhterev’s works – despite the fact that he was already one of the most famous neurologists and psychiatrists of his time – became sidelined in the Soviet Union after his death, because his later work on reflexology was viewed as being ‘vulgar-mechanistic’ and making ‘wayward idealistic assertions’ (Bol’shaya Sovietskaya Entsiklopediya, 1950: 124–5).

Some remarks on the further development of the concept of latent schizophrenia in the Soviet Union

In the mid-1920s, at the beginning of the Soviet era, no unified medical doctrine had yet been established on this issue. In forensic psychiatry, it was inheritance and organ malfunction rather than critical life events that still played the most prominent role in the genesis of psychic disorders. For example, in a textbook of forensic psychiatry issued by an official governmental publisher, malfunctions of the gonads were discussed as a possible factor in dementia praecox (literally ‘early dementia’, here in Russian, translated as ‘rannee slaboumie’) (Kosorotov, 1926: 330). Amazingly, in a footnote, there is already a hint of the new term (in Roman letters, with a spelling mistake), ‘Ccizophrenia’. By the 1940s, the concept of latent schizophrenia was already well established in Soviet science. A textbook of forensic psychiatry of that time established the term ‘thrifty state’ (in Russian, ‘iskhodnoe sostoyanie’) for schizophrenia (Sudebnaya psikhiatriya, 1949: 166). The ‘symptoms’ strikingly resemble those established by Bleuler (see above): those affected are able to conduct simple tasks, but have a disturbed sense of reality and peculiar mannerisms, and they are prone to reformism (‘reformatorstva’), in the sense of making uncritical plans for the reorganization (‘pereustroistvo’) of society. If such people became dangerous for society, the suggestion was that they would have to be cured by compulsory treatment (pp. 171–3). Social deviation of those afflicted became fixed in the concept. The Bol’shaya Sovietskaya Entsiklopediya (1957: 34) also listed as symptoms of schizophrenia: vagabonding and not being able to keep even a simple job, among other things. In the 1960s, Soviet psychiatrists defined two subtypes of ‘sluggish’ schizophrenia: a pseudo-oligophrenic and a psychopathy-like form (Banicikov and Ambrumova, 1962: 45). They also recognized ‘sluggish’ schizophrenia as an independent form of schizophrenia, with no switch into other, heavier subtypes. The main behavioural traits of the patients afflicted were: inconsiderate actions; preoccupation with abstract, mostly philosophical problems; endlessly pondering meaningless questions; wandering around aimlessly; and generally asocial behaviour (Banicikov and Ambrumova, 1962: 45). The authors point out that the most reliable method in the clinical study of schizophrenia was investigation of the course of the disease and its outcome (p. 41).

Discussion

Psychiatry in the Russian Empire at the end of the nineteenth century and the beginning of the twentieth century can be characterized by its own independent research on the diagnostic entity, which is now called schizophrenia. ‘Idiophrenia’ introduced by Kandinskii and ‘dysnoia’ by Korsakov precede the ideas established by Kraepelin and Bleuler. Moreover, Korsakov had already established a ‘dysnoia abortiva’, which was akin to Bleuler’s ‘latent schizophrenia’. However, it seems that the ideas put forward by Korsakov, in particular, had little impact on Russian and early Soviet forensic psychiatry. It was rather Kraepelin’s concept of ‘dementia praecox’ that was taken up. The adoption of ‘latent schizophrenia’ in Soviet psychiatric research very likely has its origin in the works of Bleuler. In this context, it should not be forgotten that research on latent schizophrenia was also carried out in Western countries, and particularly in the USA. The US psychologist Bertram R. Forer (1914–2000) pointed out that ‘latent schizophrenia is not schizophrenia’, but rather a risk of developing schizophrenia under certain circumstances (Forer, 1950). In addition, studies were conducted to compare features appearing in the Rorschach Test with general indices of latent schizophrenia, such as minimal loss of contact with reality, lack of conventionality, and lack of mental energy (Zucker, 1952). In Western literature at that time, psychodynamic aspects of the disorder such as hypercathexis were being discussed (Federn, 1947; Wolman, 1957).

One might assume that, before the term ‘schizophrenia’ had been established, questions of ‘hidden’ disorders appeared in other, much older concepts. An example might be the claims made by the Austro-German psychiatrist Richard von Krafft-Ebing (1840–1902), who reported in his textbook of psychiatry a bloated diagnostic concept at that time called ‘primäre Verrücktheit’ (primary madness), which at least supplied the building material for the early schizophrenia-like concepts. Von Krafft-Ebing cited a subtype of ‘primäre Verrücktheit’, which was defined by an abnormal character and also, depending on the different manifestations, the kind of man ‘who has a defect in his juridical convictions and who will become a troublemaker’ (Krafft-Ebing, 1883: 128).

Research on latent schizophrenia also brings up a nosological question which is still relevant today. The classification of psychic diseases is still based mainly on Kraepelin’s descriptive method for investigating the course of the disease, rather than finding an organic equivalent. Kraepelin had already developed his method, which he considered to be preliminary because it was the only possible way then. He was hoping it would provide new insights for a better concept in the future, and proposed it simply as a new approach to research (Trenckmann, 1988: 228). Psychiatric diagnostics is still merely descriptive. If the psychiatrist describes a symptom, then it has already occurred and cannot therefore be latent. If we focus on the course of a disease, we have to bear in mind the multiple realization of mental states. What we subsequently recognize in the afflicted person as a precursor symptom would just have been treated as a vagary of normal life in another, healthy one. Perhaps the postulate of latent psychiatric disorders is merely a contradictio in adiecto?