Psychopharmacology and the Classification of Functional Psychoses
By Thomas A. Ban and Bertalan Pethö
Four-Dimensional Classification
Affective Psychoses
Schizophrenic Psychoses
From Dementia Praecox to Schizophrenia
The first clinical description of patients, who were to be diagnosed later as schizophrenic, was in Morel's (1853) Etude Cliniques in which he described "young mental patients" with a particular kind of sudden degeneration. However, it was only seven years later in 1860 (in his Traite des Maladies Mentale's) that he termed this "sudden immobilization of all the faculties" as "demence precoce."
The concept of "demence precoce" remained dormant until Kraepelin (1893), in the fourth edition of his textbook, brought together the syndromes of hebephrenia, described by Hecker (1871), catatonia, or tension insanity described by Kahlbaum (1874), and dementia paranoides (which was singled out by him from the vast range of paranoias, under the heading of "psychological degeneration processes"). Subsequently in the fifth edition (1896) he characterized this "group of clinical conditions" by its "peculiar destruction of internal connections of the personality and a marked damage of emotional life." Because patients, belonging to this group of illnesses showed considerable resemblance to what Morel (1852, 1860) described under the term "demence precoce," Kraepelin adapted the term "dementia praecox" and used it three years later in 1899, to designate a single disease progressing towards "psychic enfeeblement" that manifests in three forms --hebephrenic, catatonic and paranoid. In the seventh edition (1904) of the textbook,
the paranoid type of dementia praecox included Magnan's (1893) "delire chronique." In the eighth edition (1909-1915), a distinction was made between the paranoid form of dementia praecox proper and other "paranoid deteriorations" referred to as "paraphrenias" (Pichot, 1983). In the paraphrenias, in contradistinction to dementia praecox disorders of emotion and volition, even if present, are not marked. To comply with the new definition, "delire chronique" was transferred to the paraphrenias (Pichot, 1983). For Kraepelin this separation remained valid on clinical grounds. It was Mayer (1921) who later subsumed paraphrenias under the heading of the schizophrenias.
Thus, in the eighth edition of his textbook, Kraepelin put forward a completely different subdivision of the group of disorders he subsumed under "dementia praecox." The new classification distinguished among 10 different forms, i.e., dementia simplex, silly deterioration (lappische Verblodung), depressive deterioration, depressive deterioration with delusional formations, circular forms, agitated form, periodic form, catatonia, paranoid form and schizophasia. It was also in the eighth edition that Diem's (1903) concept of "dementia simplex" was adapted and in which "silly deterioration" was substituted for "hebephrenia."
The changes proposed in the eighth edition remained isolated from the main stream of psychiatry. Instead, it is the classification from the fifth edition which distinguishes three forms--hebephrenic, catatonic and paranoid--that is usually attributed to Kraepelin. This classification and diagnostic approach was operationalized by Landmark (1982).
By replacing Kraepelin's nosological hypothesis by a pathogenetic one and the term "dementia praecox" with the term "schizophrenia," Blueler (1911) confirmed and consolidated the concept. He defined schizophrenias as a "group of psychoses," characterized "by a specific type of thinking, feeling and relation to the external world" which "appears in no other disease in this particular fashion." Accordingly, Bleuler distinguished between the "fundamental" and the "accessory" symptoms of schizophrenia and asserted that the fundamental symptoms -- loosening of associations, inappropriateness of affect, ambivalence and autism (referred to as the four-A's) -- are exclusive to schizophrenia, while the accessory symptoms occur in other psychiatric conditions as well. Furthermore, he assumed that the "primary symptoms" of schizophrenia--disturbance of associations, affective changes (possibly), hallucinations (possibly), stereotypes and physical disorders (such as vasomotor and pupillary changes) -- were the direct expressions of the brain disease, while the secondary symptoms were derived from the primary pathological phenomena (see Appendix XVII, Table I). With consideration to "fundamental" and "accessory," as well as "primary" and "secondary" symptoms Bleuler distinguished among four types of schizophrenia, simple, paranoid, hebephrenic and catatonic.
In the DAS, based on the DCR (Petho, Ban, Kelemen et al., 1984), substantiation of a diagnosis of schizophrenia is carried out by the evaluation of 10 variables. The variables include symptoms which can be present in any psychosis (delusions, hallucinations) and variables which are specific to schizophrenia, such as catathymic evolvement of symptoms, and dissociation among perceptual-cognitive, relational-affective and motor-adaptive functions (split). The other variables are formal thought disorder that disturbs comprehensibility (primary incoherence, tangential thinking, blocking, derailment, desultory thinking and/or onomatopoesis), affective changes (blunted, inadequate and/or inappropriate) and personality changes (abandonment of habits, change in life style, incomprehensibility of behavior and/or autistic behavior). Additional prerequisites are clear consciousness, the absence of holothymic evaluations, and the consistent presence of psychopathology for at least two weeks. Diagnoses corresponding to schizophrenic psychoses of the DCR are schizophrenic psychoses in ICD-9 and schizophrenic disorders and schizophreniform disorders in DSM-III.
In ICD-9 the diagnosis of schizophrenic psychoses is not restricted to disorders running a protracted, deteriorating or chronic course. It is not made 'however, unless there is, or has been evidence during the same illness for a characteristic disturbance of thought, perception, mood, conduct or personality. In contradistinction to the DAS criteria, however, in ICD-9 considerable emphasis is placed on disorders of the ego, such as the sense of being controlled by alien forces and that one's thoughts, feelings and acts are known to or shared by others. There is also greater emphasis placed on explanatory delusions, e.g., that natural or supernatural forces are at work and responsible for patient's clinical state.
DSM-III criteria of schizophrenic disorders correspond also with DAS criteria. In certain respects, however, the diagnosis is restricted in that the illness needs to occur before age 45 and continuous signs of the disorder must be present for at least six months. When the duration of illness is longer than two weeks but shorter than six months, the diagnosis in DSM-III is schizophreniform disorder.
In spite of its high, almost 1 percent prevalence rate in the general population -- and the recognition that the lifetime risk for children of schizophrenics is approximately 15 times higher than that of the 0.86 percent in the general population--there are no generally accepted criteria for the diagnosis of schizophrenia (Tsuang and Vandermey, 1980). The most frequently employed clinical and/or research criteria were summarized by Berner et al. (1983) in Diagnostic Criteria for Schizophrenic and Affective Psychoses. They included Schneider's (1957) First Rank Symptoms, the St. Louis Criteria (Feighner et al., 1972), the New Haven Schizophrenia Index (Astrachan et al., 1972), the Flexible System for the Diagnosis of Schizophrenia (Carpenter, Strauss and Bartko, 1973), the Present State Examination Criteria (Spitzer, Endicott and Robins, 1978a and b), Taylor and Abrams Criteria (Taylor and Abrams, 1978; Taylor, Redfield and Abrams, 1981), the French Empirical Criteria (Pull, Pull and Pichot, 1981), and the Vienna Research Criteria (Berner and Katschnig, 1983) (see Appendix VII, Tables II to V). In view of the difficulties encountered in identifying generally acceptable criteria for the diagnosis of schizophrenia and contributions of recent investigations, especially by Pope and Lipinski (1978), Koehler (1979), Pope et al. (1980) and Berner (1982), it has been suggested that schizophrenic symptoms have "no differential diagnostic weight for distinguishing between schizophrenia and cyclothymia" (referring to affective psychoses) (Berner et al., 1983). If this assumption could be substantiated by further evidence, Jaspers' (1913, 1946) hierarchical diagnostic principle would be reversed. Or in other words, diagnosis would not be determined by the pathology at the "deepest level" and therefore in case of the presence of both affective and schizophrenic symptoms the presence of schizophrenic symptoms would not outweigh the presence of affective ones.
Febreruary 6, 2025