Friday, 28.04.2017

Thomas: A Ban: In historical perspective. Peralta, Cuesta and their associates’ findings on the highest familiality of Leonhard’s classification in polynosologic study

 Ernst Franzek’s comment

 

It is a pleasure and honour to receive your invitation to give a comment on “In Historical Perspective: Peralta, Cuesta and their associates’ findings on the highest familiality of Leonhard´s classification in polynosologic study”.

In 1992, Beckmann, Fritze and Franzek published a paper in Pharmacopsychiatry on the influence of neuroleptic medication on specific syndromes and symptoms in schizophrenic patients with unfavourable long-term course who were diagnosed with Leonhard´s (1957) classification. They found   that syndromes were almost unchanged with respect to the preneuroleptic era and concluded that in schizophrenia which leads to severe residual psychopathology, Leonhard´s classification is superior to the DSM classification.

Let us shortly summarize the findings;

All 8 patients with periodic catatonia, a group with high familial loading, showed a chronic remittent course. Subsequent to good or even full remissions in the early years of the illness, new exacerbations ensued despite continuous treatment with neuroleptic medication. There were remissions of acute episodes with electroconvulsive therapy, insulin coma treatment and with high doses of neuroleptics. . After the introduction of neuroleptic medication, the often dangerously aggressive hyperkinetic psychomotor states, described in the pre-neuroleptic era, became less severe. In the period between acute outbursts of the illness, numbness and lack of motivation with psychomotor stiffness in subtle modulatory behaviour persisted despite continuous treatment with neuroleptic medication.  

There were 13 patients with affect-laden paraphrenia, a schizophrenic subgroup with high familial loading.  All patients in this subgroup fulfilled DSM-criteria of paranoid type of schizophrenia. The common symptom of these patients was marked delusion of self-reference. Acute illness was characterized by paranoid hallucinatory syndromes with prominent affective features. After treatment with neuroleptic medication, hallucinations became less frequent. However, chronic delusions of self-reference persisted. It appeared to be the decisive defective symptom of patients with affect-laden paraphrenia. Patients with affect-laden paraphrenia had the most benefit of treatment with neuroleptic medication within the group of chronic schizophrenic patients.

There were 3 patients with cataphasia, another schizophrenic subgroup with high familial loading.  In every case, the illness brought about a dissolution of thought and speech. The marked disturbance of speech and thought persisted throughout the illness despite continuous treatment with neuroleptic medication.

The following patient groups belong to sporadic, non-familial forms of systematic schizophrenia.

There were 5 patients with systematic paraphrenia. They showed paranoid, bizarre, hallucinatory symptoms and severe disturbance of thinking. . There was no free interval without psychotic features during the course of the illness. Despite continuous treatment with high doses of neuroleptic medication, the chronic paranoid-hallucinatory syndromes persisted.

Ten patients were diagnosed with systematic catatonia. In recent classifications most of these patients were diagnosed as autistic spectrum disorder. The following symptoms were found to be resistant to treatment with neuroleptic medication: autism, ambivalence, ambitendency, negativism, proskinesis, speech sluggishness, speech promptness, parakinetic movements and disturbances of thought.

Nine patients were diagnosed with hebephrenic schizophrenia. In these patients dysphoric, depressive and occasional euphoric episodes with delusions, hallucinations and ideas of reference often required hospitalization. During treatment with neuroleptic medication the positive symptoms rapidly disappeared in every case, but chronic affective flattening persisted. In some of the cases, the flattening of affect has been already obvious long before first hospitalisation. Dysphoric episodes were characteristic during the entire course of the illness. The following symptoms were resistant to treatment with neuroleptic medication: flatness of affect, querulous behaviour, and stereotype questioning and answering. Dysphoric mood swings appeared to be milder in patients on neuroleptic medication.

The effect of continuous treatment with neuroleptic medication with respect to the pre-neuroleptic era was a marked reduction of psychomotor excitement whereas the syndromes were more or less unchanged.

. The overall conclusion of the authors was that Leonhard´s classification of schizophrenia provides more suitable populations for future research than some other classifications.

Based on their findings in other studies authors raised the question that “schizophrenia” is “not a disease entity” (Franzek and Beckmann 1992, 1998)?  To date no response was received to this question.

 

References

Beckman H, Fritze J, Franzek E. The influence of neuroleptics on specific syndromes and symptoms in schizophrenics with unfavourable long-term course. Pharmacopsychiatry  1992; 26:50-58.

Franzek E, Beckmann H. Schizophrenia: Not a disease entity? A study of 57 long-term hospitalized chronic schizophrenics. European Journal of Psychiatry 1992; 6:97-108.

Franzek E, Beckmann H. Different genetic background of schizophrenic spectrum psychoses:

A twin study. American Journal of Psychiatry 1998; 155: 76 - 83.

Leonhard K.Aufteilung der endogenen Psychosen.  Berlin:Akademie; 1957.

 

Ernst Franzek

June 23, 2016