Edward Shorter’s comment on Donald F. Klein’s final comment
Thomas A. Ban: The Wernicke – Kleist - Leonhard Tradition with Special Reference to Mania, Melancholia and Manic-Depressive Psychosis
Collated by Olaf Fjetland
I sympathize with Don Klein. Looking at the list of Leonhardian diagnoses, such as "unproductive euphoria" and "fantastic paraphrenia," induces a MEGO phenomenon: "My Eyes Glaze Over." Many of these diagnoses seem to be distinctions without differences. On the whole, the field has largely rejected Leonhard.
Yet Karl Leonhard (1904-1988), professor of psychiatry at the University of Berlin, does have some influential international advocates in such places as Würzburg (the late Helmut Beckmann) and Zurich (Jules Angst). These international voices alone are a cautionary sign: Is Leonhard worth a second look?
Dr. Klein raises two questions about the Leonhardian system:
1. Is it clinically useful? Dr. Klein believes not. Yet there are patients whom DSM does not diagnose well that fall within the Leonhardian fold. John Nash, for example, the star of the book and film A Beautiful Mind, met the criteria for the Leonhardian diagnosis "affect-laden paraphrenia" (die affekvolle Paraphrenie). Nash did not have "schizophrenia," or at least not the DSM variety. Leonhard assigned the "affect-laden" diagnosis to the "unsystematic schizophrenias," which had virtually nothing in common with the systematic schizophrenias, core schizophrenia. This confusing terminology alone is one of the things that gripes people about the Leonhardian system. So, yeah, there are patients whom the Leonhardian diagnoses nail. But each Leonhardian diagnosis won't necessarily have a distinctive Gestalt, the kind of pattern-recognition that is the essence of clinical diagnosis. (DSM-5, with its chronically low kappas, is not so hot at this either.)
2. Has Leonhard been statistically verified? Dr. Klein is doubtful. Here is the one powerful piece of verification -- a singleton, to be sure, that has not been replicated (because, as far as I know, nobody has tried) -- that provokes thought. In 1962, Frank Fish at Edinburgh and Christian Astrup at the Gaustad Hospital in Oslo re-diagnosed 285 "chronic schizophrenic" inpatients on the basis of the Leonhardian criteria. The results were surprising. On the basis of responsiveness to phenothiazines, there were two clearly defined groups: The "non-systematic schizophrenias" were highly responsive to the phenothiazine "tranquilizers," especially levomepromazine and chlorpromazine. Of 43 patients with "affect-laden paraphrenia," 84.4 percent had an excellent degree of improvement; only 1 patient failed to improve. "Cataphasia" followed close behind: 78.5 percent had an excellent response, no response in 3; periodic catatonia had 60.0 percent of the patients responding, only 2 unresponsive. By contrast, patients diagnosed with "systematic schizophrenia" did poorly on antipsychotics: best was "systematic paraphrenia" (40.3 percent an excellent response); worst was "systematic catatonia": none responded well, and, of 107 patients with that diagnosis, 38 didn't respond at all.
This is not a plaidoyer for the adoption of the Leonhardian diagnoses. But DSM has turned into a scientific disaster. We need a replacement system of diagnoses. These are little beams of light
February 15, 2018