Psychopharmacology and the Classification of Functional Psychoses 

By Thomas A. Ban and Bertalan Pethö

 

Four-Dimensional Classification

 

Affective Psychoses

Schizophrenic Psychoses

Treatment of Schizophrenic Disorders

Pharmacotherapy vs Other Treatments

 

Progress in clinical psychopharmacology has focused attention on the heterogeneity of the schizophrenic population. It has also revealed that schizophrenia consists of at least two major groups of disorders. Research in clinical therapeutics, however, has not gone beyond the unitary concept of schizophrenia. One possible reason for this is that for the therapeutic management of the majority of schizophrenic patients, pharmacotherapy offers higher reliability, easier accessibility, greater simplicity and fewer hazards than any other treatments known today. Pharmacotherapy is certainly the treatment of choice for acute and chronic schizophrenics in the community where uncontrolled pathological behavior may be unacceptable. It is also usually the most effective means of shortening the patient's stay in the hospital and of preventing future readmissions (Lehmann 1975).

By now the superiority of pharmacotherapy over physical treatments -- insulin-induced hypoglycemia and electroconvulsive therapy (ECT) -- has been shown convincingly (Heinrich, Kretschmar and Kretschmar 1972). However, ECT may still be tried if schizophrenic patients fail to improve after three months or more on pharmacotherapy. Similarly, there is substantial evidence to believe that pharmacotherapy is superior to individual psychotherapy, group psychotherapy, and milieu therapy (May 1968). Nevertheless, a combination of these therapies with pharmacological treatment may be more effective than pharmacotherapy alone, especially during the rehabilitation and maintenance phases of treatment (Hogarty et al. 1973

Similarly, in one study (Goldberg, Klerman and Cole 1965) the "withdrawal dimension" could be affected by neuroleptic drugs only, while in another, the "negative (withdrawal) symptoms" such as blunted affect, poverty of speech, and social withdrawal were found to respond to social therapies (Wing, Leff and Hirsch 1973). Since the "florid symptoms" of schizophrenia correspond with Schneider's (1957) "first rank symptoms" (thought insertion, thought broadcasting, thought withdrawal, delusional perceptions, delusions of control, auditory hallucinations), the possibility has been raised that it is the "first rank symptoms" which can be controlled by neuroleptic drugs only. Nevertheless, Abrams and Taylor (1973) found no relationship between the presence of "first rank symptoms" and therapeutic responsiveness to neuroleptics.

In spite of the facts that the percentage of "symptom free" schizophrenic patients has not been increased by the introduction of neuroleptic drugs and that the therapeutic changes have been confined to a shift from the prevalence of "psychotic" to the prevalence of "residual symptoms" (Kelly and Sargant 1965), there is an impressive consensus that the treatment of choice for schizophrenia is pharmacotherapy with neuroleptics (Cawley 1967).

 The lack of increase in "symptom free" schizophrenic patients corresponds with the findings that the rate of remission has remained essentially unchanged during the past 55 years (Kraepelin 1899; Simon et al. 1965), although the discharge rate from hospitals has considerably increased. The increased discharge rate from hospitals, regardless of the presence of psychopathological symptoms, may explain the higher social remission rates found by Gross, Huber and Schuttler (1971) and Hoenig and Hamilton (1966) -- 51 and 55%, respectively -- in their (eight- and four-year follow-up) studies carried out after the introduction of new drugs. Nevertheless, the fact remains that social recovery in Achte's (1961) four-year follow-up study on patients admitted between 1953-1955, i.e., prior to the introduction of neuroleptics, is higher (65%).