Caractéristiques cliniques associées au diagnostic de schizophrénie à la Clinique Psychiatrique Universitaire de Strasbourg (1929–1931)

Objectives

The development of the concept of schizophrenia by Eugen Bleuler at the beginning of the 20th century has been the focus of numerous historical studies. Many of these studies are part of the history of ideas: they examine in particular the relationship between the newly developed concept of schizophrenia and other existing concepts, above all that of dementia praecox founded by Emil Kraepelin. Other studies relate to social history: they analyze the emergence of schizophrenia as gender-related or as a phenomenon influenced by political or economic factors. However, whether they consider schizophrenia as a scientific or as a social object, none of these studies provide a clinical description corresponding to everyday practice in psychiatric institutions at the level of the inpatient population. Studies on the history of ideas are based on clinical descriptions from psychiatric textbooks or scientific articles, and are therefore far from everyday practice. The discrepancy between science-in-the-making and published science has already been widely described. Social history studies are based on clinical descriptions from medical archives, but these only concern the situation of a single patient or a small number of patients. Moreover, they exclusively focus on the social situation of patients and not on everyday medical practice, such as diagnosing patients. The aim of this study is to describe the clinical features associated with the diagnosis of schizophrenia at the Strasbourg University Clinic of Psychiatry at the time of its introduction into clinical practices (1929–1931). We have attempted to identify those that led the psychiatrists of this institution to diagnose schizophrenia in everyday clinical practice.

Materials and methods

As the diagnosis of schizophrenia was not routinely given until 1928 at the Strasbourg University Clinic of Psychiatry, the study period was delimited from 1929 to 1931. We have stretched the study period to three years in order to avoid a selection bias due to a too short time frame. The study was based on a sample of 150 hospitalizations. This sample was randomly selected from the total of 401 hospitalizations with a diagnosis of schizophrenia identified during the period 1929–1931. The existence of another diagnosis (in addition to schizophrenia) was an exclusion criteria as we considered that this could alter the description of symptoms reported in the patient's medical files. The data were collected from patient's medical files and more specifically from the medical observations they include. We did not take into account other documents from patient's medical files (such as medical letters or medical certificates) because they were either not clinically informative or were too rarely available. Data analysis was mixed, initially qualitative and then quantitative. In the qualitative analysis, a questionnaire was developed from the medical observations of the patient's medical files in order to explore quantitatively the clinical features of the sample's hospitalizations. A thematic analysis method was used involving the construction of themes that correspond to clinical features. The medical observations of the various hospitalizations (excluding the 150 hospitalizations of the sample) were successively thematized until no new themes were identified. The hospitalizations were selected at random after stratification by gender and year. Eighteen hospitalizations were analyzed. Each theme constructed was then used to create a questionnaire item. The questionnaire developed included 130 items grouped into four axes: psychiatric symptoms, physical symptoms, history, age and gender. In the quantitative analysis, the frequency of each item of the questionnaire was established among the sample of 150 hospitalizations taking gender into account. Additional statistical analyses were performed to compare men and women.

Results

The diagnosis of schizophrenia was more frequent in women, in the 20 to 40 year old age group and when some psychiatric symptoms were reported: “verbal auditory hallucinations”, “indifferent affectivity” and “ideas of persecution”. In the analyzed hospitalizations, “Autism” was rarely reported, while “ambivalence” and “disturbed associations” were not. In the majority of analyzed hospitalizations, patients were diagnosed with at least four psychiatric symptoms corresponding to those currently used for the diagnosis of schizophrenia according to DSM 5. Physical symptoms and history were rarely reported. Overall, the clinical presentation of men and women was similar.

Conclusions

In everyday clinical practice at the Strasbourg University Clinic of Psychiatry, the diagnosis of schizophrenia relied on psychiatric symptoms, primarily “verbal auditory hallucinations”, “indifferent affectivity” and “ideas of persecution”. These symptoms had been identified by Eugen Bleuler, but they were not those considered by him to have the best diagnostic value (fundamental symptoms). Our results support a pragmatic approach to the diagnosis of schizophrenia at the Strasbourg University Clinic of Psychiatry. It could be seen as a transcription into practices of Eugen Bleuler's typical clinical description of schizophrenia, shaped by a pre-existing theoretical influence (Emil Kraepelin's typical clinical description of dementia praecox) but also by the context of hospitalization. Indeed, hospitalizations of patients with schizophrenia were motivated above all by symptoms with behavioral consequences, such as hallucinations or delusions, which may have focused the attention of psychiatrists at the expense of fundamental symptoms. While showing a clear over-representation of women in the diagnosis of schizophrenia, they also revealed that men and women were diagnosed with the same symptoms overall. The over-representation of women therefore might result rather from a lower hospitalization rate of men (compared to women presenting with the same symptoms) than from an over-diagnosis of schizophrenia in women.