Psychopharmacology and the Classification of Functional Psychoses 

By Thomas A. Ban and Bertalan Pethö

Four-Dimensional Classification

Affective Psychoses

Melancholia and Depressions

Nosological Classifications

After a detour of almost 40 years, interest in the nosology of depression and in Schneider's (1920) concept of depressive illness was revived. By combining structural analysis with a holistic approach (i.e., perceiving the patient in his totality and not just as an aggregate of psychopathological symptoms), and with consideration of all four developmental stages of depressive illness, Leonhard (1957) recognized that Schneider's "vital depression" consists of a number of different clinical syndromes. Of these only one, pure melancholia corresponds to some extent with the original concept.

However, and in contradistinction to Schneider, he considered the triad of motiveless (incomprehensible) dysthymic mood, psychomotor retardation and thought retardation as the cardinal symptoms of pure melancholia; and perceived the indecisiveness, and feeling of inadequacy (insufficiency) as secondary phenomena to the cardinal-primary manifestations. By shifting the emphasis from cross-sectional psychopathology to the unipolar-bipolar dimension of the course, Leonhard separated the melancholic syndrome of bipolar manic melancholic illness from unipolar pure melancholia, a concept introduced by Lange (1897) and Schou (1927) (Pedersen, Poort and Schou, 1947).

Similarly, by recognizing the importance of the overall (holistic) clinical picture, whether simple (monomorphous) or multiform (polymorphous), he separated unipolar pure melancholia from the unipolar pure depressions, i.e., nonparticipatory, harried, hypochondriacal, self-torturing and suspicious. These unipolar pure depressions are prevailingly affective, systematic diseases from a structural point of view, while pure melancholia is a nonsystematic disease in which thought and desire are also obligatorily disturbed.

Furthermore, Leonhard called attention to cross-sectional features distinguishing between the bipolar and unipolar forms of depression. He suggested that bipolar — nonsystematic — forms display a more colorful appearance. Also, they vary not only between the two poles, but in each phase offer different clinical pictures. The same does not apply to the unipolar — systematic — forms in which each individual form is characterized by a syndrome not associated or even transiently related to any other form and recur in patients with a periodic course with the same symptomatology (Figure 8).

The five distinct subtypes of pure depression are named on the basis of their prevailing clinical features. Although they are prevailingly affective-mood disorders, in two of them (harried and nonparticipatory) motor-adaptive structures, and in three others (hypochondriacal, suspicious and self- torturing) perceptual-cognitive structures, are also involved. Of the five subtypes, "harried" depression is characterized by motor restlessness associated with marked tension and anxiety with driven (but meager) complaintativeness and poor thematization, while hypochondriacal depression by hypochondriasis and corporization (feeling sick or diseased) with hopeless complaintativeness and homonom bodily hallucinations (bodily misperceptions).

Self-torturing depression is characterized by self-condemnation and guilt feelings with loss of self-esteem and lamentativeness, while suspicious depression by suspiciousness, ideas of reference and auditory hallucinations. Nonparticipatory depression is characterized by lack of affective participation and feelings of alienation with abulia and the feeling of loss of feelings referred to as anhedonia. In contradistinction to pure melancholia which usually ends within a limited period of time, in pure depressions, there is a tendency for chronicity. On the other hand, similar to pure melancholia, pure depressions yield to complete remission between episodes, even if the duration of the episodes is prolonged.