Ernst Josef Franzek’s comment 

Donald F. Klein’s final comment on Thomas A. Ban: The Wernicke – Kleist - Leonhard Tradition with Special Reference to Mania, Melancholia and Manic-Depressive Psychosis
Collated by Olaf Fjetland

       The analysis of the development of the currently used classification systems of mental disorders indicates that sticking to established terms and methodologies more and more impedes progress of research. Modern research requires homogenous clinical syndromes or homogenous disease spectra to examine them with improved and advanced available methodologies and technologies.

            Is the concept of a dichotomy of mental disorders, which is attributed to Kraepelin, really incompatible with a concept of several different disease spectra including a sophisticated description of clinical and nosological pictures according to Leonhard, or is there a not yet known link between them?

The prerequisite for answering above question is going back to clinical and empirical realities. Kraepelin postulated that only the cause decides on the special course and peculiarity of the mental illnesses. According to Kraepelin, it is insignificant which research methods were used because the psychoses will independently converge on identically diseases. This paradigm is the basis of Kraepelin´s prognostic dichotomy of the endogenous psychoses into a spectrum of prognostic favorable manic-depressive illnesses and a spectrum of prognostic unfavorable endogenous insanities with severe residual psychic defects. In the 8^th edition of his textbook, Kraepelin divided the spectrum of prognostic unfavorable insanities into two major groups: the “paranoid insanities” (German: “paranoide Verblödungen”) and the “Group of Dementia Praecox.”   As another special type of disease, he described the “Paranoia,” a disorder characterized with delusions of reference, delusions of grandeur, erotic delusions, delusions of persecution and other delusions. Affectivity, activity and also the logical thought processes, however, were almost undisturbed in this type of mental disease (Kraepelin 1913; 1915).  The characteristic symptoms of dementia praecox according to Kraepelin were weakening of judgment, mental initiative and creative abilities, deadening of affectivity and sympathy, loss of energy and drive, and, in particular, a loosening of the integration and unity of inner life. These processes result in a peculiar and odd destruction of the personality with prominent damages of affectivity and will functions (Kraepelin1915). There are clear similarities of the Dementia Praecox concept to the concept of Hebephrenia according to Hecker (1871) and Kahlbaum (1874; 1890).

            Kraepelin has tried to adjust his classification system again and again untill his death. He was dissatisfied because a great deal of psychoses, appearing in the daily clinical praxis, did not meet its criteria. In 1920, six years before he died, Kraepelin suggested that the scientific community should look for new strategies to classify the mental diseases (van Tilburg 1990). 

            Kleist was the first to describe remitting atypical psychoses which he originally called "autochthon degeneration psychoses." Because of their good prognosis without remaining psychic defects after remission of the acute psychotic episodes and other similarities to Kraepelin’s manic-depressive diseases, he later proposed to call them “Cycloid Psychoses.”  On the other hand, he regarded the different clinical pictures of schizophrenia as genetically based degenerations of psychic systems and dimensions. He compared them with, at that time already well-known, systematic neurological diseases (Kleist 1925; 1926; 1928).

            Leonhard´s classification of the endogenous psychoses has its roots in the work of Kahlbaum, Hecker, Kraepelin, Wernicke and Kleist. The main result of Leonhard´s lifelong studies was the differentiation of the endogenous psychoses into five distinct groups or spectra of diseases which are independent of each other with respect to symptom clusters, course, long-term outcome and genetic loading: Unipolar affective psychoses, bipolar affective psychoses, cycloid psychoses, unsystematic schizophrenias and systematic schizophrenias (Leonhard 1995; 1999). Cycloid psychoses, unsystematic and systematic schizophrenias exhibit first rank symptoms according to Kurt Schneider (1992).

            The cycloid psychoses often show bipolar clinical pictures and have a favorable long-term prognosis with respect to lacking residual psychopathology. This mainly differentiates them from the whole group of schizophrenias which have an unfavorable long-term course and outcome and have to be divided nosologically into unsystematic und systematic forms. The residual states of the schizophrenias can vary from slight forms to very serious and disabling ones. In accordance with Kleist, Leonhard (1999) regarded the systematic forms of schizophrenia as genetically determined degenerations of high and highest psychic systems in the brain. There is some resemblance with the “catastrophic schizophrenias” as described by Bleuler (1911). Most of the schizophrenias as described by Leonhard fit into Kraepelin´s dementia praecox concept. The cycloid psychoses according to Leonhard, however, have to be allocated to the spectrum of manic-depressive illnesses in Kraepelin´s system because of their prognostic favorable long-term outcome.

             Leonhard´s classification is complex and asks for a thoroughly clinical training. It can be clearly stated that Leonhard’s approach is a sophisticated further development of Kraepelin’ s dichotomic system. In this context, a serious scientific discussion over apparently conflictive positions seems to be necessary. Probably the combination and integration of both diagnostic approaches, which so far appear mutually exclusive, will drive the research forward again. Classification systems have to be free of any dogmatic ideation and irreversible paradigms. This could bring a new dynamic in research and clinical praxis and new insights in the puzzle of mental disorders.

References:

Bleuler E. Dementia praecox oder die Gruppe der Schizophrenien. Leipzig Wien, Deuticke, 1911.

Hecker E. Die Hebephrenie. Ein Beitrag zur klinischen Psychopathologie. Virchows Arch 1871; 52:394-429.

Kahlbaum K. Über Heboidophrenie. Allg Z Psychiat 1890; 46: 461-474.

Kleist K. Die gegenwärtigen Strömungen in der Psychiatrie. Berlin Leipzig, De Gruyter, 1925.

Kleist K. Über zykloide Degenerationspsychosen, besonders Verwirrtheits- und Motilitäts-psychosen. Arch Psychiatry 1926; 78: 100-115.

Kleist K. Über zykloide, paranoide und epileptoide Psychosen und über die Frage der Degenerationspsychosen. Schweiz Arch Neurol Psychiatr 1928; 23:37.

Kraepelin E. Psychiatrie. III Band, 8. Auflage, Leipzig, Barth, 1913.

Kraepelin E. Psychiatrie. IV. Band, 8. Auflage, Leipzig, Barth, 1915.

Kahlbaum K. Die Katatonie oder das Spannungsirresein. Berlin, Hirschwald, 1874.

Leonhard K. Aufteilung der endogenen Psychosen und ihre differenzierte Ätiologie. 7. Auflage, Stuttgart, Thieme, 1995.

Leonhard K. Classification of Endogenous Psychoses and their Differentiated Etiology. Second, revised and enlarged edition, Wien New York, Springer, 1999.

Schneider K. Klinische Psychopathologie. 1. - 14. Auflage, Stuttgart, Thieme, 1950 – 1992.

van Tilburg W. De psychiater en Kraepelin. Tijdschrift voor Psychiatrie 1990; 32:16/30.

December 7, 2017