In 1981, the most detailed socialist-period study in Bulgaria dedicated to childhood schizophrenia and childhood autism appeared. Its author, psychiatrist Meglena Achkova, based her analysis on clinical material from sixty children whom she had followed for twenty years at the children’s psychiatric clinic in Sofia.Footnote 1 Below are some of her observations:
...K. V., from early childhood, was strange, withdrawn, and did not adapt to the children’s community. At the age of 5, he learned to read, after which he became excessively absorbed in reading… At the age of 9, he spent an entire year writing a work he titled “The Phaethonians.”… considered it scientifically grounded, and believed it described the inhabitants of the lost planet“Phaethon,” who had allegedly come to Earth 100,000 years ago…Footnote 2
...E. M., a child who had already exhibited behavior deviating in an autistic manner, developed the following ritual around sitting on the potty at the age of 5. He would go to the next room and call out several times, “Hey, guys, come, come… like that.” Then he would run to his mother and gaze into her eyes. She, in turn, had to look back at him for a while and then say, “I know, Zhenya.” This would be followed by his remark, “Mom, let’s do an enema.” Only then would he sit on the potty.Footnote 3
...These children [who are verbal and display “autistic fantasies”—G. M.]—ask, from an early age, overly intelligent yet peculiar and abstract questions for their age: “What holds the moon in the sky?” “Why does the wind blow?” “Who created me?”Footnote 4
...Y. A., age 3: Did not ask questions… Recently, she has been engaging in a behavior where she arranges her fingers in a stereotyped interwoven way at an angle outside her visual field and watches them from the periphery of her vision … In the ward, among other children, she plays as if she is alone…Footnote 5
The psychiatric cases cited above raise several questions that this article seeks to explore, namely: Why were children with such diverse behavioral, affective, and communicative deviations placed within a common classification group? What united them and what distinguished them within that group? How was the broad diagnostic category, which encompassed heterogeneous forms of “withdrawal” from the “real world” constructed, and (why) did it produce puzzling associations?Footnote 6 The title of Achkova’s book, Schizophreniia in Childhood, set the general conceptual framework under which the so-called “syndrome of early infantile autism” was also situated, yet Achkova herself did not consider her views indisputable: “All theoretical pursuits we will present are merely approaches toward understanding this exceptionally complex problem.”Footnote 7
This article examines a topic that has remained entirely unexplored to date: the historical representations of autism in socialist Bulgaria. The Bulgarian case, however, is approached within a broader comparative perspective in order to assess its local historical specifics, social meanings, and cultural importance. Whereas in the 1960s autism was regarded as a very rare condition, recent statistics indicate a rising prevalence worldwide.Footnote 8 Yet even today, approximately eighty years after the psychiatrists Leo Kanner (1943) and Hans Asperger (1938) introduced the term “autism,” coined by Eugen Bleuler (1911), to designate a new diagnostic entity, the causes for this “explosion” as well as the definitions, etiology, and therapies of “autism spectrum disorders” (ASD) still remain contested.Footnote 9 Тhe heterogeneity of the autism concept becomes even more pronounced when we account for its ongoing reconfiguration over time and its considerable historical variation across different social and political contexts. As Mark Osteen has argued, autism is an “extraordinarily unstable category” because it “epitomizes the ambiguities of ‘disability itself.’”Footnote 10 Discourses on autism shed light on the constitution of our visions of (ab)normality, as projected by social institutions. The uncertainties surrounding our historical and contemporary cultural narratives on autism require critical analysis.Footnote 11
The historical reconstruction of the contradictory and dynamic concepts of autism offers an opportunity to revisit the fragile boundaries between biological pathology and social norm, as well as the barriers between scientific and political reality.Footnote 12 In this context, the question arises as to what extent the social-historical narrative of autism in Bulgaria is meaningful and specific precisely as a socialist narrative. Although the first mentions of “early infantile autism” in Bulgarian publications date back to the second half of the 1960s, it came into psychiatric focus during the 1980s, whose socio-political climate set a specific ideological backdrop. To borrow the theoretical distinction proposed by Mat Savelli, I suggest that the theories and practices related to childhood autism in Bulgaria during the period under study were more socialist by default (shaped by the socialist context) than socialist by design (driven solely by ideological purity).Footnote 13
The main goal of this article is to trace the historical dynamics of the normative models for (re)shaping the so-called “early infantile autism” in socialist Bulgaria. Hence, answers to the following questions are engaged: to what extent, why, and how did Bulgarian psychiatrists adopt, modify, combine, and/or confront these models? How did the vision of extreme isolation and social aloneness, ascribed to autism, fit into the conceptual and ideological frameworks of socialist psychiatry? What was its disability politics? The empirical data of analysis includes textbooks, monographs, and articles in child psychiatry, archival materials from the archival collections of the National Institute of Neurology, Psychiatry, and Neuropsychiatry (NINPN), and of the Sofia Psychiatric Dispensary, as well as semi-structured interviews with contemporary psychiatrists. Methodologically, their interpretation here combines social history and disability studies through discourse analysis.
My hypothesis is that autism occupied a seemingly paradoxical position in Bulgarian psychiatric discourse from the late 1960s onwards. On the one hand, experts described it as “the most discussed and most intriguing problem in child psychiatry”; on the other hand, they emphasized its limited social significance, given the rarity of the condition.Footnote 14 Only a few Bulgarian specialists worked on autism, yet child psychiatrists were few in general and those who did focus on autism held considerable institutional influence.
Amid the “Babylonian confusion” of theories about early childhood autism, Bulgarian psychiatrists usually treated it as a polyethiological syndrome.Footnote 15 Although it could manifest as an organic or psychogenic disorder, or even as a form of psychopathy in Hans Asperger’s sense, it was most often conceptualized as an “initial stage” of childhood schizophrenia. This view aligned with the classifications of the Moscow psychiatric school, led by Andrei Vladimirovich Snezhnevskii, and taken up by Soviet child psychiatrists such as Moisei Vrono, Vera Bashina, V.P. Kudriavtseva, and O.P. Iur´eva.Footnote 16 In this framework, the small number of autism cases became an integral feature of what was perceived as “big psychiatry,” the domain centered on the processual nature of schizophrenia. Autism offered an opportunity to study the pathological mechanisms of schizophrenia from their earliest developmental manifestations. Such thinking reinforced the idea that autism served as a simplified model of schizophrenic illness in adults. At the same time, autism helps illuminate key aspects of the development of Bulgarian child psychiatry. Because the diagnosis itself was filled with ambiguities and conceptual gaps, it operated in an active space where scientific schools, theories, and institutional practices intersected. Perceptions of autistic disorders followed dominant medical models grounded in Soviet psychiatry, yet they also revealed cracks in the scientific-political and ideological canons. Through these gaps—gradually widening as the scientific-ideological climate in Bulgaria “thawed” after the 1960s—western conceptual approaches and clinical practices discreetly entered the psychiatric discourse. Ultimately, we should not underestimate the ideological commitments that shaped the general trajectory of Bulgarian child psychiatry. At the same time, these commitments do not exhaust its development, since the field—despite its specific socialist modifications—still followed global conceptual trends.
Below, I will try to map some of the key theoretical lines, around which the postwar representations of autism were developed by psychiatric and psychological discourses from both sides of the Iron Curtain. First, I will provide a brief review of the classifications and discussions regarding the infantile autism concepts in the postwar period. Second, I will interpret the discourse on early infantile autism in Bulgaria against the background of global biopolitics. To this aim, I will outline the main concepts of the psychiatric discourse regarding the “syndrome of early infantile autism” and will then inscribe them in the cultural and ideological framework of (ab)normality during state socialism. I will address the etiological explanations, clinical pictures, and therapy options related to autism. The analysis will also trace the transfer of psychiatric concepts behind and beyond the Iron Curtain. In conclusion, I will try to highlight the main features of the social construction of autism during the socialist period in Bulgaria with regard to some of its (dis)continuities in the postsocialist period.
The Emergence of a Disorder and the Fluidity of its Classifications
The normative models for responding to autistic children in any society form part of its shifting conventions of “(ab)normality.” These conventions do not simply describe deviations from value-neutral biomedical standards. They carry a prescriptive, that is, normative force: they delineate the boundaries of what counts as normal, and those boundaries inevitably embed broader social standards. Following Ian Hacking’s insight that “we need to make room, especially in the case of our most serious psychopathologies, for both the constructionist and the biologist,” my analysis argues that the concepts of autism in a given society emerge from the interactions between psycho-medical frameworks and wider sociocultural scripts.Footnote 17
Contemporary debates among supporters and critics of the neurodiversity movement raise the question of whether autism represents a “deficit, difference, or both.”Footnote 18 Such a dilemma was globally irrelevant and even inconceivable during the period under review. The reasons lie in the different historically specific “regimes of truth” (régime de la vérité) surrounding autism.Footnote 19 A productive way to unpack the particular meanings of autism in a given context is Hacking’s notion of an “epistemology of assemblage.” It requires scholars to “reconstruct the epistemological field that allows certain things to be considered true at particular historical moments, and the kinds of entities, concepts, explanations, presuppositions, assumptions, and types of evidence and argument that are required if statements are to count as true.”Footnote 20 Following Hacking, Maija Nadesan called autism a “niche” disorder, one, “that emerged and was created in relation to cultural practices and discourses specific to particular points in time, the transition from the nineteenth to the twentieth century and, more recently, the transition from the twentieth to the twenty-first centuries.”Footnote 21
As already mentioned, Leo Kanner and Hans Asperger were the two pioneers who almost simultaneously, but independently of one another, constructed the concept of autism. In “Autistic Disturbances of Affective Contact,” Kanner presented brief case studies of eleven children (eight boys and three girls), nine of Anglo-Saxon origin and two Jewish, with most coming from upper-middle class families.Footnote 22 He borrowed the term “autism” from Eugen Bleuler, the psychiatrist who coined the modern concept of schizophrenia, who had, in turn, adapted the concept from Sigmund Freud.Footnote 23 Thus, extreme solitude and withdrawal from the social world were interpreted psychoanalytically as a defense mechanism. Leo Kanner outlined “two essential features of the condition: (1) autism or severe problems in social interaction and connectedness from the beginning of life, and (2) resistance to change/insistence on sameness,” including stereotyped movements.Footnote 24 In 1938, Asperger published his account on the social difficulties, unusual interests and high verbal skills of the boys he examined.Footnote 25 He published in German, which likely accounted for its lower popularity when compared to Kanner’s later article at the time of its release.
During the 1950s and 60s, Freudian psychotherapy dominated the epistemological field of the autistic syndrome, and it was widely regarded as a result of parental, particularly maternal failure.Footnote 26 Bruno Bettelheim’s famous theory of “refrigerator mothers” amplified Kanner’s occasional remarks about parental emotional coldness and had “worldwide repercussions.”Footnote 27 Whereas nineteenth-century social anxieties focused on abnormal children of the lower classes and their maladjustment to society, the post–WWII psychotherapeutic gaze shifted to middle-class children. Cold, distant mothers were blamed of causing traumatic autistic reactions. Furthermore, the idea of the “schizophrenogenic mother” portrayed her as embodying numerous harmful traits: domineering, emotionally cold, rejecting, and overly controlling, while inducing guilt. When such a mother was paired with a father depicted as passive, distant, and ineffective, their son was thought to grow up confused, insecure, and at heightened risk of developing schizophrenia.Footnote 28 In the 1950s and 60s, many child psychiatrists conceptualized autism as a form of schizophrenia (childhood schizophrenia).
The first and the second Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (APA) classified symptoms of the type Kanner and Asperger described as “schizophrenic reaction, childhood type.”Footnote 29 In the eighth revision of the International Classification of Diseases, ICD-8 (1965), the category of infantile autism appeared, but was similarly arranged under the schizophrenia grouping.Footnote 30 Kanner himself changed his initial ideas and attributed autism to the schizophrenia spectrum, but separated it from childhood schizophrenia. The conceptual mixture and ambiguity of autism concepts in the postwar period was impressive and difficult to navigate. The atypical behavior of autistic children fell under an array of possible diagnostic categories: infantile autism, Kanner’s syndrome, childhood autism, atypical psychosis, and childhood schizophrenia. The ninth revision, ICD-9 (1975) included infantile autism in the category of psychoses with specific childhood origin. It was only in 1980 that DSM-III included autism as a distinct diagnostic category (infantile autism) within the group of pervasive developmental disorders, thereby separating it from schizophrenia.Footnote 31
This conceptual change resulted from new research, such as by Israel Kolvin. In 1971 he differentiated autism from schizophrenia by demonstrating that children who were diagnosed with schizophrenia as adults did not show autistic behavior as children.Footnote 32 However, the links between autism and schizophrenia persisted through the 1980s in some cases, such as the Soviet Union. In 1992, ICD-10 officially pronounced forms of autism, including Asperger syndrome, as pervasive developmental disorders. In the Russian Federation, the ICD-10 was adapted through adding a new section to the category of schizophrenia: “schizophrenia, childhood type.”Footnote 33 According to Waltz, in Russia, “as an ‘upper-middle-class’ condition (not to mention one associated with Jewishness), autism was defined as a disease of the capitalist system. As such a thing couldn’t possibly exist under communism, autistic symptoms were always given a different label—and parents were seen as suspect for more than just their parenting skills.”Footnote 34
Historians have pointed to a number of pragmatic factors that helped shape Soviet psychiatry’s special focus on schizophrenia; for example, its relatively high prevalence, the significant disability associated with it, and the resulting chronic shortage of hospital beds.Footnote 35 These concerns reinforced the push for early prevention of schizophrenia and, in turn, encouraged an excessive expansion of the diagnostic category itself. From the 1920s on it became an umbrella term for various borderline cases and even normal forms of anxiety, sadness, or neurotic manifestations.Footnote 36
Interestingly, the concept of sluggish schizophrenia—later notorious as a political tool of repression against Soviet dissidents—first entered Soviet psychiatry through child psychiatry.Footnote 37 Andrei Snezhnevskii developed the notion initially introduced by Grunia Efimovna Sukhareva (1891–1981), who headed the Children’s Psychosis Clinic at the Institute of Psychiatry and chaired the childhood section of the Moscow Society of Neurologists and Psychiatrists between 1938 and 1965. By hybridizing various concepts and research contributions, Sukhareva distinguished sluggish from rapid schizophrenia based on the onset of the disorder (before or after puberty) and its tempo. This model made it possible to situate diverse clinical manifestations of schizophrenia along a single continuum and include within it a range of borderline and supposedly premorbid forms.Footnote 38
As Benjamin Zajicek noted, “Sukhareva’s research on sluggish schizophrenia grew out of a study of schizoid psychopathy in children.”Footnote 39 A growing body of scholarship argues that she was the first to describe what is now known as Asperger’s syndrome, nearly two decades before Asperger himself. Sukhareva’s clinical observations of six boys aged eleven to fourteen revealed a shared inclination toward abstract and schematic thinking, а tendency toward solitude, various automatisms, shallow emotions, and motor insufficiency. She also emphasized the necessity of a differential diagnosis between schizoid psychopathy and schizophrenia. Although localized in “common brain systems,” in her view they were not identical: while the former was a congenital constitutional anomaly, the latter represented a morbid process with destructive tendencies.Footnote 40
However, Soviet psychiatrists from the 1960s to the 1980s, and later, interpreted childhood autism in the conceptual framework of “constitutional and procedural dysontogenesis” within the “schizophrenic spectrum.”Footnote 41 Sukhareva’s disciple Moisei Sh. Vrono, who from 1965 to 1988 headed the Children’s Psychosis Clinic at the USSR Academy of Medical Sciences’s Research Institute of Psychiatry, wrote about the syndrome of early infantile autism: “According to our observations, most often it is still associated with schizophrenia or, at least, with a hereditary predisposition to schizophrenia, in which early infantile autism may be an expression of premorbid features (homonomic background, psychopathy), latent schizophrenia, pre-manifest dysontogenesis, or finally, a manifestation of various stages of childhood schizophrenia courses—initial, manifest, or post-procedural (residual).”Footnote 42
According to Vera Bashina, one of the leading Soviet specialists on early childhood schizophrenia and autistic disorders, Kanner’s syndrome occupied “an intermediate place in the continuum of constitutional and procedural dysontogenesis of the schizophrenic spectrum.” Bashina distinguished Kanner’s syndrome as a rare “evolutionary-procedural disorder,” and “childhood autism of procedural genesis,” which de facto was equated with childhood schizophrenia.Footnote 43 In any case, despite the subtle and sometimes ambiguous distinctions, the boundary between the different forms of autism remained slippery and conditional, and their manifestations did not leave the gravitational field of schizophrenia—both in Soviet and Bulgarian child psychiatry during the period under consideration.
Bulgarian Child Psychiatry: Historical, Cultural, and Ideological Frameworks of Autism during the Socialist Period in Bulgaria
Some of the sparse publications on the social history of psychiatry during the postwar period in Bulgaria begin in quite a similar manner: with the observation that this research field remains largely understudied.Footnote 44 Despite the growing academic interest in the social studies of Bulgarian psychiatry, historical reconstructions are provided mainly by psychiatric experts from “orthodox,” medical disciplinary perspectives.Footnote 45 Comparative transnational approaches are mostly lacking.Footnote 46 This is particularly true for the history of child psychiatry in Bulgaria. But before delving further into the scientific and ideological influences on this field, and in particular on the concept of autism, it is necessary first to outline its general contours as theory and practice.
In 1947, the first children’s psychoneurological hospital in Bulgaria was established in Sofia, which became the children’s ward of the psychiatry department’s clinic in 1969. Shortly after, a children’s psychiatric department was also opened at the Research Institute of Psychoneurology (the Institute’s name being changed in the years to come).Footnote 47 The Research Institute of Neurology, Psychiatry and Neurosurgery was founded in 1972 through the integration of the existing Scientific Institute of Neurology and Psychiatry, the Departments of Neurology and Psychiatry at the Medical Academy, and the Departments of Neurology, Psychiatry, and Neurosurgery at the Institute for Specialization and Qualification of Physicians (ISUL [ИСУЛ]). As part of the institute, four clinics were established, including the third, a pediatric psychiatric clinic. In 1975, the first national Manual on Child Psychiatry was published, edited by Hristo Hristozov.Footnote 48
Among the main principles of Bulgarian child psychiatry, Hristozov outlined the “evolutionary-dynamic approach” to childhood psychiatric disorders; complex, multidisciplinary approaches in prevention, treatment, resocialization; and the principle of socialist humanism.Footnote 49 These were characteristic of the Moscow school mentioned above, alongside the nosological orientation traced back to Emil Kraepelin. Describing the historical development of Bulgarian psychiatry, Hristozov emphasized its scientific accomplishments, including work on topical research problems, publications in Bulgaria and abroad, international cooperation, and the provision of expert consultation to various social institutions on issues of child mental health.Footnote 50 Alongside these accomplishments, however, this analysis suggests that child psychiatry in Bulgaria developed late and with limited capacity. The existence of only two child psychiatric wards in the entire country and thirteen medical offices for children attached to psychoneurological dispensaries in 1970 were among the indicators of systemic deficiencies. Statistical records reveal that in 1980, the children’s clinic at the Research Institute of Psychoneurology had sixty-five beds across two departments, staffed by two habilitated and six non-habilitated doctors; psychiatrists.Footnote 51 Numerous programs outlining the institute’s activities, including the ones in the children’s psychiatric clinic, and its reports from the 1970s and 1980s consistently and self-critically documented the chronic issues in Bulgarian child psychiatry (and psychiatry more broadly): insufficient material resources (such as dispensaries, hospital wards, beds, and medical equipment), lack of personnel and specialization opportunities, inadequate prevention, treatment and social rehabilitation for children under dispensary and hospital care, and a growing lag compared to other socialist and also capitalist countries.Footnote 52 Not least, the lack of interaction and coordination between child psychiatrists engaged in prevention and therapy, on the one hand, and pediatricians and defectologists, on the other, was repeatedly emphasized.
Gencho Pirʹov, one of the founders of defectology in Bulgaria, defined the field as a science related to psychology and pedagogy, concerned with “the study and education of children suffering from physical or mental deficiencies.”Footnote 53 Despite the formally declared intentions to promote cooperation between defectologists and psychiatrists in Bulgaria, in cases of disorders perceived as psychoses rather than constitutional defects, the leading position remained with the medical model applied by psychiatrists, including in the case of childhood autism. As Pir´ov noted, the child neuro-psychiatric hospital in the Sofia district of Pavlovo served as a “distribution center” for the different categories of “defective children.”Footnote 54 Kristina Popova has pointed out that “in compliance with the system for classifying children with developmental problems, established in Bulgaria in the 1950s, they were distributed among institutions depending on the degree of mental impairment.”Footnote 55 Oligophrenia, a general category for children with delays in intellectual and psychological development, encompassed three subcategories of children: morons, imbeciles, and idiots. For the mildest case (morons), the state provided auxiliary schools. The more severe categories (imbeciles and idiots) were placed in institutions under the jurisdiction of the Ministry of Public Health and Social Welfare, with age, sex, and place of origin also being taken into account. These institutions operated under a closed regime and typically stood isolated in villages or border regions. Their overall organization actively produced the exclusion and stigmatization of children with intellectual disabilities.Footnote 56 Oligophrenopedagogy, a central branch of defectology, focused its psychological and pedagogical interventions on children enrolled in auxiliary schools. As Popova argued, defectology “followed the Soviet model of the late Stalinist period.”Footnote 57
What, then, was the broader ideological framework shaping child psychiatry in socialist Bulgaria? In a 1977 article, Prof. Ivan Temkov, head of the Department of Psychiatry at the Higher Medical Institute in Sofia, 1971–83, described the pervasive influence that Soviet psychiatry exerted on its Bulgarian counterpart.Footnote 58 This influence extended from the adoption of educational programs, through the “excellent Soviet psychiatric literature” used in education, to the selection of topics and methods in research. Furthermore, Temkov stated, Bulgarian psychiatrists persistently sided with their Soviet colleagues when they were accused of misusing psychiatry to surpress political dissidents; most notably through Andrei Snezhnevskii’s diagnostic category of sluggish schizophrenia. Footnote 59
When examining the socialist ideological norms that structured scientific psychiatric paradigms in Bulgaria, the so-called mature socialism period should be the primary focus. It is during these years that child psychiatry made its first steps and the first Bulgarian descriptions and conceptualizations of “early infantile autism” appeared in specialized scientific publications. In 1978, an article entitled “Lifestyle and Mental Health,” published in the journal Neurology, Psychiatry and Neurosurgery, declared:
If today the capitalist way of life represents a mass psychological trauma on the higher nervous activity of many millions of workers, through the uncertainty of both the present and the future… socialism creates conditions for a calm, confident and optimistic existence…The liberation of labor from exploitation removes an entire system of psychological and other superstructures that generate a negative attitude towards labor itself and towards society as a whole, leading to the isolation and alienation of man, to his transformation into a “recluse” and a “shipwrecked person” amid the waves of relentless life, a “loner” in an animal kingdom….Footnote 60
Interestingly, in western popular psychological theories of the 1960s and 70s autism was often mobilized as an emblem of the culturally induced “aloneness” of modern man, attributed to the atomization of contemporary society.Footnote 61 Although this line of argument was not explicitly articulated in Bulgarian texts on childhood autism, it can be read as resonating with the broader normative framework shaped by the ideological pathos of “socialist humanism.” According to Hristozov, socialist humanism “embodies everything most progressive in the care for children and adolescents, overcomes all forms of prejudice, and fosters a spirit of humanity and comradeship.”Footnote 62 Within such a framework, autism—understood as withdrawal from the social world, a disruption of interpersonal connectedness, and a form of maladaptation—could be interpreted as standing in tension with the collectivist ethos that underpinned socialist conceptions of the person. As Achkova wrote, “ultimately, autism is a ‘schism,” a disintegration of the diverse interpersonal connections in which a normal person engages and through which they regulate their behavior—a loss of connection with the real world.”Footnote 63
Socialist ideology countered the perceived dangers of social atomism by emphasizing the therapeutic value of collective belonging. As Mitev, Ivanov, and Ivanova put it, this consisted in “the awareness that you are not alone in life and that you can always count on the understanding and comradely mutual assistance of the members of the collective.”Footnote 64 Mental disabilities, however, did not disappear in the transition to “mature socialism.” Although, as the authors claimed, such conditions occurred less frequently than in capitalism, ideological discourse framed them either as remnants of the capitalist way of life or as side effects of the scientific-technological revolution. Similarly, the Program for the Protection and Improvement of the Mental Health of Bulgarian People, adopted in 1976, emphasized the dual effect of socialist society on mental health: on the one hand, socialism created conditions for the expression of society’s “protective forces,” while on the other, a number of new “pathogenic” psychosocial factors emerged, such as the stress produced by intense modern life and scientific-technological progress.Footnote 65 Against this background, psychiatry took a key biopolitical role in its capacity as “the most effective psychoprophylaxis that has existed in human history,” that is, to build “harmoniously developed, ‘crystal clear’ personalities.”Footnote 66 In the same vein, the 1976 program called for the broad promotion of psychohygiene and psychoprophylaxis.Footnote 67 As the program explicitly stated, this goal required “coordinated monitoring of children and adolescents through systematic control of mental development, including the identification of at-risk groups.”Footnote 68
In 1984, towards the end of the socialist regime, the Bulgarian Communist Party Central Committee issued a decree that launched a Program for Comprehensive Research of Man and His Brain. The document placed “the problem of the scientific-technological revolution and of man as a biopsychosocial being” at the center of interdisciplinary expert efforts involving national defense, education, and healthcare.Footnote 69 Although framed in the language of Marxist-Leninist philosophy, the Program also revealed the ambition of Bulgarian academic elites to draw from western advances in neuroscience, molecular genetics, and cybernetics. Its conceptual framework demanded the acceleration of socialist man’s intellectual development, the unblocking of their barriers to social integration, and the mobilization of “hidden brain reserves” for social (re)adaptation and overall societal progress. The Program did not mention early infantile autism, yet some of its strategies and planned activities targeted adjacent child psychiatric conditions. It introduced selective disability policies affecting children with learning difficulties, particularly those falling under the category of so-called “minimal brain dysfunction,” and children with exceptional abilities. The Program called for mass screening examinations to identify at-risk groups of children with developmental disorders and gifted children, to determine their numbers and establish appropriate corrective, rehabilitative, and stimulatory measures, including early vocational guidance.
The activity plans of the National Institute of Psychiatry, Neurology, and Neurosurgery during the 1980s highlighted the topics of the brain research program as priorities for the Institute’s studies, as well as for its staffing and material support.Footnote 70 These plans defined one of the priority topics as “optimization of intellectual development in childhood and adolescence.”Footnote 71 In this regard in 1987, the General Assembly of NINPN (National Institute of Neurology, Psychiatry and Neurosurgery) reported conducting neurological and neuropsychological studies on 600 children, with electrophysiological studies performed on 198 of them.Footnote 72 The official documents of the NINPN stated that in the context of the overall restructuring (perestroika) in the country, the study of “the reserves, adaptation, and compensatory capabilities of the brain” would ultimately contribute to “utilizing all the possibilities and advantages of socialism.”Footnote 73 Thus, it could provide impetus to overall social(ist) progress.
An important issue in interpreting the numerous programmatic documents with medico-psychiatric relevance from the socialist era is the practical meaning of their obligatory ideological rhetoric. My hypothesis, which will be further developed in the analysis, is that ideological rhetoric often served as a decorative wrapper, especially in the later years of the regime, for strategies that were otherwise difficult to reconcile with it. This rhetoric played a primarily ritual function, legitimizing the respective text by embedding it within an empty ideological matrix. This does not, however, negate the need for a discursive analysis to test this hypothesis in each specific case and to disentangle the various intentions and semiotic strategies within the texts. Therefore, in the following section I will examine how clinical and research experience specifically related to autistic disorders fitted into this situation of chronic deficits, coupled with scientific and ideological optimism.
Autism during Socialism: The Psychiatric Discourse behind and beyond the Iron Curtain
The first, albeit limited, mentions and analyses of childhood autism in specialized psychiatric periodicals date back to the 1960s. At the First congress of Bulgarian neurologists, psychiatrists, and neurosurgeons in 1967, Hristo Hristozov and Meglena Achkova presented a case of “early childhood autism,” which they interpreted as a form of schizophrenia.Footnote 74 The following year, Achkova and Nadezhda Dashinova discussed a similar case during a session of the Sofia branch of the Scientific Society of Pediatricians. On this occasion, Academician Georgi Uzunov stressed that the concept of autism was not accepted in the clinic under his supervision. Most discussants agreed that the nosology of this condition remained unspecified, but in the particular case presented most likely concerned a manifest form of schizophrenia.Footnote 75 In this way, a new concept entered Bulgarian psychiatric discourse in the second half of the 1960s, although its initial appearance was indistinct.
In the two editions of his child psychiatry textbook (1975, 1983), Hristozov underscored the controversial nosology of infantile autism.Footnote 76 Referring to his joint work with Achkova, Hristozov pointed out that, according to them, autism was an “initial state of a very early childhood schizophrenia.”Footnote 77 Тhe second edition of the same textbook added that the understanding of autism as “the earliest formed psychotic syndrome” was getting increasingly important.
Тhe view that the discourse on autism remained marginal in Bulgaria during the period under discussion gains support from the fact that Achkova was virtually the only widely recognized researcher working in this field. This assessment, however, becomes more complicated when we consider another factor: Achkova held an influential position as a leading figure in Bulgarian child psychiatry, a field already lacking enough specialists. The jointly presented scientific reports of clinical cases of early infantile autism (such as those co-authored with Nadezhda Dashinova), also show that Achkova’s professional circle at the Child Psychiatry Clinic and the Psychiatry Department at the Higher Medical Institute, where she served as associate professor, contributed to her clinical and academic work in one way or another. One example appears in the clinic’s 1985 annual activities plan. Under the section “Educational and Teaching Work,” item 1 assigned to Dr. Liubomir Zhivkov the task of preparing “an additional video for illustrating teaching (focused on autistic children).”Footnote 78 Among other things, this interesting detail indicates the growing relevance of the “exotic” topic of autism within routine teaching activities.
As for regular clinical practice, the sparsely preserved archive of the Child Psychiatry Clinic in Sofia mentions the term “autism”—more precisely “early infantile autism”—for the first time in 1980, in an annual hospital report.Footnote 79 The reference appeared in a commentary on statistical data regarding the number of treated patients and clinical outcomes, serving as a kind of disclaimer about the lack of significant therapeutic effect for certain groups of patients: “The percentage of patients without improvement has significantly decreased, although it cannot be reduced to zero due to the fact that the clinic admits patients for diagnostic clarification and treatment with conditions such as early childhood schizophrenia, early infantile autism, oligophrenia, and other similar conditions, for which significant improvement in health status cannot be expected during their relatively short stay in the hospital.”Footnote 80 In the annual hospitalization reports from this and subsequent years, however, the term did not appear as an independent nosological category. The reports and accompanying forms were compiled in accordance with the ICD-9 classification schemes, which subsumed autism under the category “psychoses with origin specific to childhood” (code 299). Under this category, the 1980 report recorded five children with this diagnosis out of a total of 240 patients treated that year at the clinic, most of whom were from Sofia and other major cities.Footnote 81 In the following year, 1981, seven children were listed under this diagnosis, six of whom were first-time admissions. Five were children under the age of 14, and six were discharged by the end of the year; collectively, they accounted for 146 inpatient days.Footnote 82 The duration of hospitalization for children with this diagnosis can also be inferred from a preserved document issued to the mother accompanying a child with “early infantile autism,” coded 299.00 (ICD-9), indicating an eight-day hospital stay.”Footnote 83
These numbers are comparable to the data recorded by the Child and Adolescent Unit at the Sofia Psychiatric Dispensary, which explicitly included “early infantile autism” as a nosological category: five children in 1985, eleven in 1987, and thirteen in 1989.Footnote 84 The numbers may seem small, but they become far more significant in light of Achkova’s observation that nine out of ten childhood psychoses from the endogenous spectrum went undiagnosed. She attributed the unreliability of epidemiological data to the ambiguous boundaries of childhood autistic syndrome, the insufficient training of psychiatric personnel, and the objective rarity of the manifestations of infantile autism and childhood schizophrenia.Footnote 85
Achkova described autism as a syndrome that, in most cases, either evolved into a schizophrenic process or was secondary to other organic diseases. It could also manifest in autistic psychopathy (now referred to as Asperger’s syndrome) or as psychogenic autism, for instance as a result of severe and prolonged institutionalization and social isolation of the child.Footnote 86 She repeatedly emphasized the complexity and contested nature of the disorder and its conceptualizations—much like its paradigmatic counterpart, adult schizophrenia—and stated that every new theory or scientific approach had been applied in efforts to explain it.Footnote 87 As she wrote, “The condition is only now emerging from the stage of clinical differentiation, and questions regarding its nosological unity continue to be a subject of heated debate.”Footnote 88 She concluded that only a preliminary, rather than a definitive, conception of childhood schizophrenia and autism was possible, and formulated it as follows:
Childhood schizophrenia is a disorder genetically linked to adult schizophrenia. It faces the same unresolved issues as schizophrenia in general: the diagnostic boundaries of the disorder, its homogeneity or heterogeneity, and the possibility that some cases are phenocopies arising due to organic or psychogenic factors. A large number of early infantile autism cases are likely very early-onset schizophrenic processes.”Footnote 89
When the symptoms appeared later in childhood—as a regression following a period of relative development—Achkova defined the autistic picture as a “secondary syndrome of childhood autism.”Footnote 90
Throughout the western psychiatric literature up to the late 1970s, the links between autism and schizophrenia were largely interpreted through a psychoanalytic lens. In Bulgaria, however, autism was conceptualized as an early form of schizophrenia within the framework of biological psychiatry—above all in its the Soviet variant. During the period under study, Bulgarian psychiatrists treated research on schizophrenia as a top priority because they regarded it as one of the most socially significant mental disorders. The 1979 report on the scientific activities of the Department of Psychiatry illustrates this focus; it listed four projects devoted to schizophrenia, covering twenty three specific studies and involving more than thirty department members. That year alone, the department examined over 500 patients. Bulgarian researchers developed work on the topic of schizophrenia epidemiology in collaboration with the Institute of Psychiatry of the USSR Academy of Medical Sciences, while the subject of “disability in schizophrenia” advanced through international cooperation with the WHO Mental Health Division.Footnote 91
When discussing autism as schizophrenia, however, Achkova did not take extreme positions, instead skillfully navigating between opposing theories. Her monograph was not a mere reflection of the Soviet psychiatric perspective but offered an erudite and insightful review of the state of the art in Germany, France, and the US. At first glance, Achkova’s approach appeared eclectic. On the one hand, her conceptualizations of early infantile autism placed it within the nosological framework of schizophrenia; on the other, they granted it a degree of distinctiveness, emphasizing its specific characteristics as clearly defined by Leo Kanner. However, representatives of the Moscow child-psychiatric school displayed a similar dual approach. Vera Bashina described it as “dichotomous” and justified it with the dual nature of infantile autism, which she understood both as a constitutional disorder and as a psychosis. Moreover, as Bashina’s herself put it:
In such verification we also see a deontological aspect. A diagnosis of this kind makes it possible, at an early stage of the child’s development, to avoid the formidable label of schizophrenia, thereby sustaining hope in the positive physiological potentialities of ontogenesis. At the same time, such double diagnosis signals to the clinician that what is at stake is an ongoing process with all the ensuing consequences–knowledge that is essential for determining the appropriate treatment, rehabilitation, and prognosis.Footnote 92
Although this acknowledgement appeared in a later, 1999 publication, Bashina herself underscored its historical significance, noting that the monograph distilled more than thirty years of work in the field. In the 1980s, Achkova drew exactly the same ethical boundaries: “Considering how socially stigmatizing a schizophrenia diagnosis was, it should only be applied with full conviction. In this sense, we considered it deontologically justified to retain diagnoses such as ‘early infantile autism’… at least until the course of the illness showed with certainty its processual nature. Sometimes this required a very long period of observation.”Footnote 93
In light of the above, separating scientific and ethical positions from the ideological obligations of Bulgarian psychiatrists proves difficult. Meglena Achkova exemplifies this dynamic: loyalty to Soviet models appears inevitable, at least within the framework of the officially declared scientific and doctrinal commitments. Her critical reflex also emerged in relation to the differential diagnosis of childhood autism and oligophrenia. Achkova rejected Kanner and Eisenberg’s claim that the parents of children with early infantile autism were usually intellectuals with a high “social status.” According to her, “Perhaps only parents with high intelligence can describe the peculiarities of the child’s behavior sufficiently accurately and comprehensively, so that it is not referred to the category of ‘oligophrenia’ by doctors insufficiently familiar with the symptoms of Kanner’s syndrome (something that happens very often).”Footnote 94 Achkova argued that sometimes, early-onset schizophrenic processes can lead to conditions indistinguishable from severe oligophrenia. She noted that almost all authors dealing with childhood schizophrenia also paid attention to what Tatyana Pavlovna Simson called oligophrenic-like effect, with which part of the cases ended.Footnote 95 Simson herself was one of the founders of Soviet child psychiatry and head of the children’s department at the USSR Academy of Medical Sciences Institute of Psychiatry (1945–60). Similar to G. Sukhareva, she played an important role in research on children’s “schizoid psychopathy,” and later became a leading expert in early childhood schizophrenia.Footnote 96
In a 2018 interview, Achkova clearly distinguished between so-called “oligophrenics” and “autistics” based on their emotional reactions: while the former were described as “affectionate,” the latter appeared “withdrawn.” Yet as she herself acknowledged in 1979, there were instances in which children with schizophrenic and/or autistic manifestations, were misdiagnosed as having oligophrenia.Footnote 97 Such children consequently acquired the stigma of mental retardation and were subjected to institutionalization in social care homes.Footnote 98
Notably, in her 2018 interview Achkova expressed hesitation about which prognosis for a child’s future development was “scarier”: that associated with mild intellectual disability or that linked to autism. She emphasized that a child diagnosed with oligophrenia may prove more emotionally lively, curious, and communicative, whereas with an autistic child, “you never know what they know and what they are capable of.”Footnote 99 My analysis therefore suggests that certain value orientations permeated expert reasoning and demonstrated the impact of socio-cultural factors on clinical judgement. Alleged autistic aloneness and unpredictability seemed more troubling than the intellectually disabled but emotionally more reliable “oligophrenics.” Аutistic children, as other groups of disabled children, could be included in the group of so-called “troublesome kids” (trudni detsa), whose very impairments raised doubts about their capacity for social adaptation. As a result troublesome kids became a central target of medico-pedagogical interventions. Experts had to identify them, explore and enhance their remaining potential, and guide them in ways that aligned their abilities with the goals of the common social good.Footnote 100
Since early infantile autism was interpreted as a possibly early form of schizophrenia, clinicians could apply the therapeutic approaches used for schizophrenic disorders to these children as well. Although Bulgarian experts expressed cautious reservations, the broad arsenal of pharmacological and other invasive means to combat psychopathology remained available—albeit with limitations—for cases diagnosed as childhood autism/schizophrenia. This arsenal included electroconvulsive and insulin coma therapy (so-called “active (shock) methods”), neuroleptics, and sociotherapy.Footnote 101 The mentioned lower age limit of 9 or 12 years, from which ECT was deemed permissible, suggests its limited use; however Achkova and Hristozov made clear they had completely refrained from applying it in their own practice.
Simultaneously, the same specialists reported using insulin coma therapy on four children by 1976, “during a period when psychopharmacological agents were not yet widely adopted in psychiatric practice.”Footnote 102 Only one child showed a “brief remission,” while there was an unjustified risk of convulsions during episodes of hypoglycemic coma. Achkova described the case of a 5-year-old girl who during insulin treatment, in a state of hypoglycemia, “experienced a temporary exacerbation, hallucinating abundantly (visually), feeling intense fear bordering on horror.” The specialists considered this therapy excessively risky and of questionable value, and therefore “almost abandoned” it.Footnote 103 The insulin-coma cases Achkova discussed involved patients with schizophrenic symptoms. However, given the clinical overlap between autism and schizophrenia, the use of such methods for treating certain borderline cases cannot be entirely ruled out.
Alongside standard treatment with neuroleptics, clinicians also carried out experimental studies that sought to provoke psychopathological symptoms (so-called experimental psychoses) through the use of DLK-20 (a chemical analogue of LSD). Achkova stated that such experiments targeted mentally defficient and schizophrenic patients, both children and adults. She argued that the findings demonstrated “in a simplified model, the dependence of psychopathological phenomena on the level of development.”Footnote 104
Achkova emphasized the need for psychotherapy even in cases of endogenous psychoses, which in children overlapped with medico-pedagogical interventions (education). For autistic children, she considered several approaches particularly suitable, especially “conditioning methods aimed at establishing correct behavioral stereotypes.” Footnote 105 Although classical conditioning drew on Pavlov’s physiological doctrine of conditioned reflexes—which shaped the socialist psychiatric framework—it also formed the basis of behaviorism and western behavioral therapies. Achkova explicitly referred to different versions of learning theory, which rested on associations between stimuli and responses, and on learning through the consequences of patients’ actions.
Overall, Achkova argued for an individual approach to each clinical case, given the absence of strict protocols and the availability of only general therapeutic guidelines. She applied the same flexible logic to decisions about hospitalization, a step that parents of very young children aged two to five usually (and understandably) opposed.Footnote 106 It is worth emphasizing that in her review of possible psychotherapies, Achkova mentioned psychoanalytically-oriented ones first, although without offering any substantive assessment of them.Footnote 107 In sync with Soviet psychiatry, Bulgarian experts rejected psychoanalytic approaches to autistic children during the socialist period. However, they could not completely avoid psychoanalytical interpretations, not least because they were at the basis of autism’s genesis as a significant object of the psychiatric gaze. In this context, Achkova acknowledged the influence of the family environment on the clinical presentation of childhood schizophrenia and autism, but correctly warned that embracing the unproven theory of “schizophrenogenic parents” only “intensifies the sense of guilt in already deeply psychotraumatized families.”Footnote 108
Although they followed Soviet psychiatric models, Bulgarian psychiatrists participated in a broader transnational transfer of concepts outside the Iron Curtain, especially in the 1980s, when they developed concepts for autism. They published in international journals, participated in transregional professional forums, and took part in academic networks. As illustrated by the Program for the Main Directions in the Activities of the NINPN, 1985–88, the state formally supported bilateral and multilateral cooperation “with socialist and some capitalist countries.”Footnote 109 According to the same program, it also encouraged the involvement of foreign scientific institutes and “prominent lecturers from abroad” in the organization of postgraduate training courses for psychiatrists.”Footnote 110
In this context, a major French-Bulgarian exchange of professional experience took place in the 1980s through two colloquia featuring the renowned French psychoanalyst Serge Lebovici.Footnote 111 The discussions highlighted a key difference between the two national groups of participants: the French school did not accept any direct equivalence between childhood schizophrenia and adult schizophrenia. In their view, schizophrenia represented only one of several possible developmental trajectories of psychotic behavior in children. At the same time, both sides acknowledged the proximity between the notion of pre-psychosis advocated by the French school and the concept of premorbid personality used by Bulgarian psychiatrists. Lebovici also accepted the important role of genetic factors in the etiology of childhood psychoses, while Bulgarian participants evaluated the French psychotherapeutic methods and day hospitals as offering an “optimistic way of active intervention.” After the second meeting, both groups stressed the need to continue cooperation despite “seemingly insurmountable differences.” The positive tone matched what Valentin Kalinov describes as a broader tendency within 1980s Bulgarian psychiatry: the “pursuit of ‘productive dialogue’ with Freudianism.”Footnote 112
The limited archival material also suggests that Bulgarian experts gained greater confidence as equal partners in international scientific and institutional exchange. For instance, in 1982 Achkova took part in a mission to the Federal Republic of Germany for a course on planning mental health care.Footnote 113 During a discussion of her report at the NINPN, she stated that many of the activities observed abroad were already being implemented in Bulgaria, and therefore, in her opinion, did not require formal adoption (the so called vnedriavane) of foreign experience.
By contrast, participants in the general annual reporting meeting of the NINPN in March 1988—at the very end of the period under study—expressed far less optimism about the state of national science and clinical practice. As neurologist Elena Tsvetanova argued, “Every attempt at cooperation with science in other countries receives no response at all. Our contacts and scientific missions abroad are few. Our capable and intelligent assistants cannot attend congresses and scientific symposia.”Footnote 114 At the same meeting the psychiatrist Assen Zhablenski described a perceived disciplinary crisis, a sentiment likely linked to broader, though publicly unspoken, sense of impending socio-political collapse in the country.
Schizophrenic stigmatization in Bulgaria continues today, as the diagnosis of schizophrenia often replaces the diagnosis of autism once a child turns eighteen. Parents of children with disabilities have protested against this practice, and their activism highlights the persisting relevance of the problem.Footnote 115 The question of conceptual and therapeutic continuity has not lost its importance, nor has the stigma towards people with autism significantly diminished. The history of psychiatric discourse on autism in socialist Bulgaria sheds more light on the heterogeneity and highly variable diagnostic criteria of medical diagnosing.
If we return to the clinical cases with which this article began, from a contemporary perspective it seems problematic to subsume under the general schizophrenic label children who are “excessively absorbed in reading” and ask “intelligent but strange abstract questions,” on the one hand, with nonverbal patients or those absorbed in their stereotyped rituals, on the other. This contrast underscores the continued need to interrogate the boundaries of the social construction of autistic categories and their ethical implications. The historical reconstruction of autism in socialist Bulgaria reveals the difficulty of disentangling scientific and ideological narratives, while also showing that the former cannot be entirely reduced to the latter.
During the period under review, the small number of identified cases of infantile autism can be understood as a form of under-diagnosing, with all the consequences for children who likely received the misdiagnosis of “oligophrenia.” Autism also remained concealed under the umbrella of schizophrenia, that not only overshadowed its specifics, but also entailed the possibility of hospitalization without entirely excluding the possibility of more aggressive medical therapies. Diagnostic and therapeutic practices remained in line with Soviet psychiatry. This explains why, although autism was emancipated internationally from schizophrenia during the 1970s and 80s, the Bulgarian model remained within the gravitational field of schizophrenic disorders. At the same time, however, from the 1980s onward the psychiatric discourse on childhood autism began to open to western, especially French normative models. Local attitudes toward psychoanalytical methods remained critical, but increasingly flexible, “tolerant,” and receptive. The ideological framework became more elusive, although it should not be underestimated: troublesome, unpredictable, and withdrawn autistic kids deviated from the socialist normative ideal of the human. These normative models, however, did not exclude only autistic children, but also, to varying degrees, other individuals with intellectual disabilities. At the same time, psycho-medical models were not unique to socialist child psychiatry, but shared some common features with western psychiatric discourses of the period. The historical and ideological regime of socialism, however, makes it possible to identify and explain certain conceptual preferences and tendencies that shaped the epistemological regime of knowledge about autism in Bulgaria during the 1980s. The utmost significance of autism lay in the opportunity it offered psychiatric discourse to detect early and study schizophrenia “in miniature”: the sublime object of psychiatry.
With some reservation, one may suggest that although the syndrome of early infantile autism was placed under the umbrella of schizophrenia, it functioned more as a conceptual patch: borrowed from Soviet models, yet striving to detach and attain nosological autonomy. The ambiguities surrounding childhood autism—linked to, yet partly differentiated from, childhood schizophrenia—may reflect both deficits in psychiatric knowledge and strategic attempts to secure ideological acceptability within Bulgarian expert discourse.
In the post-socialist period, stigma emerges from the opposite direction, but with no less force: the danger now lies not in underdiagnosing, but in overdiagnosing an expanding range of spectrum conditions. The situation highlights the need for the historical disability scholarship to inform the general public about the risks of the medical model of normalcy and the neurotypical, and to present alternative ways of thinking and acting aligned with the ethos of neurodiversity. The elasticity of the normative criteria for autism and their shifting meanings over time represent the biosocial nature of disability. Moreover, the historical reconstruction of autism within the Bulgarian psychiatric discourse, during the 1960s to the 1980s, traces the conceptual dynamics of child psychiatry shaped by the interaction of medical and ideological regimes of normativity.
Gergana Mircheva is an Assistant Professor at the Institute of Philosophy and Sociology, Bulgarian Academy of Sciences. She holds Master’s degrees in Law and in Cultural Studies, and a PhD in Cultural Studies from Sofia University St. Kliment Ohridski. Her research interests include the social and historical studies of medicine, psychiatry, and eugenics, as well as disability studies, bioethics, and biopolitics.
