Excerpt: Bleuler on Autism (1911)

Presented below is the text which coined the term "autism". Transcribed from E. Bleuler, Dementia Praecox, pp. 63-68, for source see this twitter post.

The Compound Functions

The complex functions which result from the coordinated operations of the functions previously discussed, such as attention, intelligence, will, and action, are, of course, disturbed to the extent that the elementary (simple) functions on which they depend are altered. Only association and affectivity have to be considered here. However, schizophrenia is characterized by a very peculiar alteration of the relation between the patient's inner life and the external world. The inner life assumes pathological predominance (autism).

Relation to Reality: Autism

The most severe schizophrenics, who have no more contact with the outside world, live in a world of their own. They have encased themselves with their desires and wishes (which they consider fulfilled) or occupy themselves with the trials and tribulations of their persecutory ideas; they have cut themselves off as much as possible from any contact with the external world.

This detachment from reality, together with the relative and absolute predominance of the inner life, we term autism1.

In less severe cases, the affective and logical significance of reality is only somewhat damaged. The patients are still able to move about in the external world but neither evidence nor logic have any influence on their hopes and delusions. Everything which is in contradiction to their complexes simply does not exist for their thinking or feeling.

An intelligent lady who for many years was mistaken for a neurasthenic "had built a wall around herself so closely confining that she often felt as if she actually were in a chimney." An otherwise socially acceptable woman patient sings at a concert, but unfortunately once started she cannot stop. The audience begins to whistle and hoot and create a disturbance; she does not bother a bit, but continues singing and feels quite satisfied when she finally ends. A well-educated young woman, whose illness is hardly noticeable suddenly moves her bowels before a whole social gathering and cannot comprehend the embarrassment which she causes among her friends. During the course of about ten years, a patient gave me from time to time a note on which the same four words were always written and which signified that he had been unjustly incarcerated. It did not make any difference to him if he handed me a half-dozen of these notes at the same time. He did not understand the senselessness of his action when one discussed it with him. Withal, this patient showed good judgment about other patients and worked independently in his ward. Very frequently schizophrenics will give us numerous letters without expecting any answer; or they will ask us a dozen questions one after another without even giving us time to answer. They predict an event for a certain day, but are so little bothered when the prophecy does not come to pass that they do not even seek to find explanations. Even where reality has apparently become identical with the patient's pathological creations, it will often be ignored.

The wishes and desires of many patients revolve around their release from the hospital. Yet they remain indifferent to the actual discharge. One of our patients who has a marked complex about children made an attempt to murder his wife because she only bore him four children in ten years. Yet he is quite different to the children themselves. Other patients are in love with someone. If this person is actually present, he makes no impression on them at all; if he does, they do not care. One patient constantly begs to be given the key to the door of his ward. When it is finally given to him, he does not know what to do with it and returns it almost at once. He tries a thousand times each day to open the door. If it is left unlocked, he becomes embarrassed and does not know what to do. He continuously pursues the doctor at each of his visits with the words: "Please, Doctor." Asked what he desires, he appears surprised and has nothing further to say. A woman patient asked to see her doctor. When she was summoned to the interview, she at least was able after a few minutes of perplexity to make her wishes known by pointing to his wedding ring. For weeks on end, a mother exerts every means at her command to see her child. When permission is granted her, she prefers to have a glass of wine. For years a woman longs for a divorce from her husband. When at long last she gets her divorce, she refuses to believe in it at all, and becomes furious if she is not addressed by her husband's name. Many a patient consumes himself with anxiety over his imminent death but will not take the least precaution for his self-preservation and remains totally unmoved in the face of real danger to his life.

Autism is not always to be detected at the very first glance. Initially the behavior of many patients betrays nothing remarkable. It is only on prolonged observation that one sees how much they always seek their own way, and how very little they permit their environment to influence them. Even severe chronic patients show quite good contact with their environment with regard to indifferent, everyday affairs. They chatter, participate in games, seek out stimulation---but they are always selective. They keep their complexes to themselves, never saying a word about them and not wishing to have them touched upon in any way from the outside.

Thus the indifference of patients toward what would be considered their nearest and dearest interest becomes understandable. Other things are of far greater importance to them. They do not react any more to influences from the outside. They appear "stuporous" even where no other disturbance inhibits their will or actions. The external world must often appear to them as rather hostile since it tends to disturb them in their fantasies. However, there are also cases where the shutting off from the outside world is caused by contrary reasons. Particularly in the beginning of their illness, these patients quite consciously shun any contact with reality because their affects are so powerful that they must avoid everything which might arouse their emotions. The apathy toward the outer world is a secondary one springing from a hypertrophied sensitivity.

Autism is also manifested by many patients externally. (Naturally, this is, as a rule, unintentional.) Not only do they not concern themselves with anything around them, but they sit around with faces constantly averted, looking at a blank wall; or they shut off their sensory portals by drawing a skirt or bed clothes over their heads. Indeed, formerly, when the patients were mostly abandoned to their own devices, they could often be found in bent-over, squatting positions, an indication that they were trying to restrict as much as possible of the sensory surface area of their skin.

Misunderstandings stemming from the autistic thought processes can hardly ever, or only with great difficulty, be corrected by the patients.

A hebephrenic lies on a bench in a thoroughly vile mood. As she catches sight of me, she attempts to sit up. I beg her not to disturb herself. She answers in an irritated tone that if she could sit up she would not be lying down, apparently imagining that I was reproaching her for lying on the bench. Several times, using different words, I repeat the suggestion that she remain laying quietly as she was. She merely becomes more and more irritated. Everything I say is interpreted falsely by her in the sense and direction of her autistic train of thought.

The autistic world has as much reality for the patient as the true one, but his is a different kind of reality. Frequently, they cannot keep the two kinds of reality separated from each other even though they can make the distinction in principle. A patient heard us speaking of a certain Dr. N. Immediately afterwards he asks whether it was a hallucination or whether we had spoken of a Dr. N.---Busch (doing reading experiments) has demonstrated the very poor ability of patients to differentiate between idea and perception.

The reality of the autistic world may also seem more valid than that of reality itself; the patients then hold their fantasy world for the real, reality for an illusion. They no longer believe in the evidence of their own senses. Schreber described his attendants as "miracled up, changeable individuals." The patient may be very aware that other people judge the environment differently. He also knows that he himself sees it in that form but it is not real to him. "They say, that you are the doctor, but I don't know it," or even "But you are really Minister N." To a considerable extent, reality is transformed through illusions and largely replaced by hallucinations (twilight states, Dämmerzustände).

In the usual hallucinatory conditions, more validity is, as a rule, ascribed to the illusions; yet the patients continue to act and orient themselves in accordance with reality. Many of them, however, no longer act at all, not even in accordance with their autistic thinking. This may occur in stuporous conditions, or the autism itself may reach such a high degree of intensity, that the patients' actions lose all relation to the blocked-off reality. The sick person deals with the real world as little as the normal person deals with his dreams. Frequently both disturbances, the stuporous immobility and the exclusion of reality, occur simultaneously.

Patients who show no clouding of consciousness often appear much less autistic than they really are because they are able to suppress their autistic thoughts or, like certain hysterics, seem to be occupied with them only in a theoretical way, and ordinarily allow them only very little influence upon their actions. These patients rarely remain under our observation for very long because we are inclined to discharge them as improved or cured2.

A complete and constant exclusion of the external world appears, if at all, only in the most severe degree of stupor. In milder cases the real and the autistic worlds exist not only side by side, but often becomes entangled with one another in the most illogical manner. The doctor is at one moment not only the hospital-physician and at another the shoemaker S., but he is both in the same thought-content of the patient. A patient who was still fairly well-mannered and capable of work, made herself a rag-doll which she considered to be the child of her imaginary lover. When this "lover" of hers made a trip to Berlin, she wanted to send "the child" after him, as a precautionary measure. But she first went to the police, to ask whether it would be considered as illegal to send "the child" as luggage instead of on a passenger ticket.

Wishes and fears constitute the contents of autistic thinking. In those rare cases where the contradictions to reality are not felt at all, it is the wishes alone which are involved; fears appear when the patient senses the obstacles to the fulfillment of his wishes. Even where no true delusions arise autism is demonstrable in the patients' inability to cope with reality, in their inappropriate reactions to outside influences (irritability), and in their lack of resistance to every and any idea and urge.

In the same way as autistic feeling is detached from reality, autistic thinking obeys its own special laws. To be sure, autistic thinking makes use of the customary logical connections insofar as they are suitable but it is in no way bound to such logical laws. Autistic thinking is directed by affective needs; the patient thinks in symbols, in analogies, in fragmentary concepts, in accidental connections. Should the same patient turn back to reality he may be able to think sharply and logically.

Thus we have to distinguish between realistic and autistic thinking which exist side by side in the same patient. In realistic thinking the patient orients himself quite well in time and space. He adjusts his actions to reality insofar as they appear normal. The autistic thinking is the source of the delusions, of the crude offenses against logic and propriety, and all the other pathological symptoms. The two forms of thought are often fairly well separated so that the patient is able at times to think completely autistically and at other times completely normally. In other cases the two forms mix, going on to complete fusion, as we saw in the cases cited above.

The patient need not become conscious of the peculiarity, of the deviation of his autistic thinking from his previous realistic type of thinking. However, the more intelligent patients may for years gauge the difference. They experience the autistic state as painful; only rarely as pleasurable. They complain that reality seems different from what it was before. Things and people are no longer what they are supposed to be. They are changed, strange, no longer have any relationship to the patient. A released patient described it, "as if she were running around in an open grave, so strange did the world appear." Another "had started to think herself into an entirely different life. By comparison, everything was quite different; even her sweetheart was not the way she had imagined him." A still very intelligent woman patient considered it a change for the better that, at will, she could transpose herself into a state of the greatest (sexual and religious) bliss. She even wanted to give us instructions to enable us to do likewise.

Autism must not be confused with "the unconscious." Both autistic, and realistic thinking can be conscious as well as unconscious.

  1. [Footnote 19 in original] Autism nearly coincides with what Freud has termed auto-erotism. Since, however, for this author the concepts of libido and erotism are so much broader than for other schools of thought, his term cannot very well be used here without giving rise to many misunderstandings. In essence the term, autism, designates in a positive way the same concept that P. Janet (321) formulated negatively as "the loss of the sense of reality." However, we cannot accept Janet's term without discussion because he understands this symptom in a far too general sense. The sense of reality is not entirely lacking in the schizophrenic. It fails only in relation to matters threatening to contract his complexes. Our relatively advanced hospital cases can very correctly comprehend and retain such experiences and events which are irrelevant to their complexes. These patients can give detailed anamneses which turn out to be quiet correct. in short, they show daily that they have not lost their sense of reality, but that this capacity is inhibited or falsified in certain connections. The very same patient who for years never seemed to bother about his family can, when he is anxious to escape from his persecutors in the hospital, suddenly come up with a number of perfectly correct and valid reasons why he is so badly needed at home. However, this does not prevent him from not drawing the other consequences of his deliberations. If he were really discharged form the hospital, or if easy conditions for release were offered to him, it would never occur to him to do anything to realize his "longing" for his family. 

  2. [Footnote 20 in original] The very common preoccupation of young hebephrenics with the "deepest questions" is nothing but an autistic manifestation. The "questions" about which they are so concerned are those that cannot be decided because reality has no part in them. Freud considers doubt and uncertainty as a preliminary stage of what he calls auto-erotism. (cf. Jahrbuch für Psychoanalyse, Vol. 1, p. 410). 

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