Friday, 24.03.2017

Comment by Hector Warnes

Hector Warnes’ comment on Thomas A. Ban’s Psychopharmacology and the Classification of Functional Psychoses

Professor Ban’s monograph is a monumental overview on the historical, semantic, hermeneutical, psychopathological, nosological, neuropharmacological and the latest impressive advances of neurosciences in the realm of the functional psychoses. Professor Ban, who is quite familiar with German, Hungarian, French, British and American psychiatry, offers us a tour de force spanning over 150 years.  He attempts to bridge gaps in the light of the latest clinical and neuroscientific research. Functional psychosis should not be confused with Psychogenic psychosis.  Functional psychosis actually means that so far we have not found structural alterations in the brain but we are advancing in the findings of biochemical lesions, disturbances in synaptic transmission and alterations in SPECT, PET and some biological markers.

We are far from creating a Periodic Table as Dimitri Ivanovitch Mendeleeff did based on the weight of atomic particles, though we are closer to what Carolus Linneus accomplished in creating his classification on genera and species. Ban proposes an integration of longitudinal developmental and cross-sectional psychopathological   features as well as a shift of emphasis from the interpretation of symptoms to detection of affected psychopathological structures.  He added that this novel classification has yet to be validated in clinical research. There are two issues in his mind:  firstly, whether diagnostic groups are the same in different cultures, and secondly, whether biological homogeneity can be identified by selecting subtypes of an experimental population in psychiatric research.  It reminds me of the issue of selecting the right antibiotic for the right patient according to culture and sensitivity testing of body fluids. As he pointed out, there are several attempts at multi-axial diagnosis. He noted that the term “axes” refers to the independence of its components, while “dimension” refers to the relationship of the components in a time sequence: ‘hence, the four dimensions, or rather developmental stages, include cross-sectional psychopathology, onset-etiology, course of illness and outcome (or end-stage) features’ (p. 9). Citing various authors, he agrees that we must be able to identify sites of dysregulation and map neurobiological circuits, which would mean, in his original assertion that we must be able to detect the differences in the pathologies in the processing of signals in the brain and in the organization of these pathologies in time. So far, we cannot find absolute categories but only dimensions of various scope and degrees. Indeed, the amount of correlations is staggering and we are not certain that they are cause or effect, primary or secondary. We have all seen multiples etiologies resulting in one syndrome, and contrariwise, one etiology resulting in a cluster of symptoms. Precisely, the blurring of boundaries of classifications has led to the concept of spectrum disorders and so far, there is no proof, at least in psychiatry, of one gene one illness.

Prof. Ban offers us a classification that endures scientific premises breaching the gap with the medical model. He further argues: ‘Canadian critics of his conceptual approach to diagnoses, however, contend that the quest for reliability, operational rigor and completeness has overshadowed concern for validity, clinical flavor and psychodynamic understanding’. The same critics argue that the dismissal of psychodynamic formulations and neglect of humanistic approaches to complex and ambiguous realities reflect an arid view of psychiatric diagnoses. In my reading of Prof. Ban’s paper, he does not exclude psychogenic or sociogenic factors in triggering mental illnesses. Otherwise, he would not give the pre-eminence he gives to the concept of psychogenic psychosis, which is analysed further on. More than specificity or non-specificity, or a reductionist versus a gestalt view, I would refer to a feedback loop that affects a vulnerable individual to various degrees according to multiple factors. Psychological trauma is a case in point because its effects depend on the nature, duration,  intensity and capacity for coping of each individual, without leaving aside his genetic background and his previous experiences prior to the traumatic event (allostatic load).

I support Prof. Ban’s classification of five endogenomorphic axial affective syndromes: depressive, manic, dysphoric unstable mixed and stable mixed: ‘Common characteristic by these axial syndromes are the disturbances of biorhythm manifest in the diurnal variation of symptoms and sleep disturbances’ (p. 33, with its outward manifestations of dynamic expansion,  restriction and instability, i.e., rapid fluctuations or swings).

Petho, Ban, Keleman, Ungvari, Karczag, Bitter and Tolna published, in 1984,   ‘The experimental Diagnostic Criteria for the diagnoses of functional Psychosis’. This classification basically considers psychogenic, endogenous or undifferentiated types, which are further sub-divided into 396 items, presented in 12 tables, each representing one step in the differential diagnostic process. It closely resembles Leonard’s classification. Ban’s statement that diagnoses should be made by considering the course of the illness for at least five years subsequent to its onset. He further adds: ’rhythmicity-periodicity, polarity and deterioration ought to be distinguished from the contextual characteristics such as time spent in hospital, nature of therapies’ (p. 50). He brings to our attention that such variables as form of onset, cross-sectional psychopathology, course of illness and outcome features are not sufficiently distinct.

On page 54, Ban listed the most advanced technology used in the last decade in neurosciences and concludes: ‘the increasing use of this new technology is transforming psychiatry from a descriptive into an experimental discipline--- the meaningfulness of the findings generated by the new sophisticated technology depends upon whether they can be linked to a clinical diagnostic category’.

It is, indeed, the common observation that Ban emphasizes, ‘clinical experience has shown that a differential therapeutic response to antipsychotic drugs indicates biological heterogeneity…indicating that psychosis consists of more than one diagnostic group’ (p. 58R).

Ban classifies acute psychogenic psychosis into regressive, affective and paranoid, on the one hand, and subacute onset types into four variants: passionate,  litigious, hypochondriacal and symbiotic (folie a deux), each with its own particular sub-types.        

As Ban noted, we have not surpassed Kahlbaum’s nosological entity, published in 1874, regarding etiology, cross-sectional psychopathology and course of illness (p. 94) and further, he recognized the low prognostic validity of the two classical diagnoses of dementia praecox and manic-depressive illness, ‘creating a diagnostic gap in which patients suffering from a number of different illnesses are given the same diagnoses’ (p. 99).

This far reaching investigation, which has enormous research prospects, should be published in a book. Ban lists the classifications in three types: Empiristic and Pragmatic, Genetic and Experimental and Nosological.       

Any psychiatrist with a long experience would be quite familiar with the evolution of our young field, but there is no doubt that Griesinger and Wernicke, and later the Moral treatment and Freud made significant contributions to our field. This is a holistic approach that has gained importance no matter if the psychosis is symptomatic, functional or psychogenic. The disease may arise from the body, the brain, the environment or the genes or combinations of all of these to various degrees.

We must prepare our students in the basics of psychopathology as Ban reminds us, which includes: cross-sectional psychopathology; form of onset; course of illness; outcome or end-state; and response to pharmacotherapy.


Hector Warnes

April 2, 2015