Psychopharmacology and the Classification of Functional Psychoses
By Thomas A. Ban and Bertalan Pethö
Four-Dimensional Classification
Affective Psychoses
Schizophrenic Psychoses
From Schizophrenia to the Schizophrenias
The first information on the natural course of schizophrenia dates back to Kraepelin (1899, 1919) who described dementia praecox as a disease which as a rule is progressive particularly in regard to emotional deterioration. In a few cases the process may come to a standstill. Some of the symptoms may even disappear. Far more commonly, however, the outcome is profound deterioration.
Accordingly, Kraepelin's figures for a group of inpatients at the Heidelberg Hospital showed that of the 12.6% who had a complete remission first, 8.5% relapsed three to six years later and only 4.1% remained well. The figure of 12.6% could be raised to 13.3% by adding to it all the cases with only a mild defect and to 17% by extending it to all the cases that would live a more or less socially adjusted life independent of the degree of defect (Hoenig 1967). On the other hand, 70% of Kraepelin's dementia praecox patients deeply deteriorated.
The three crucial figures of Kraepelin on the natural course of schizophrenia are full recovery, 4.1%; social remission, 17%; and deterioration, 70%. It is interesting to note the little variation in these figures during the prepsychopharmacological era. Thus, Evensen (1904) in his first study reported 15% social remissions, a figure somewhat lower than Kraepelin's. His sample consisted of male schizophrenics younger than 26 years first admitted to the Gastaud Hospital between 1887 and 1896. The evaluation was based on a five- to 15-year follow-up.
After a similar follow-up period on a sample of 815 schizophrenic patients discharged from the Gastaud Hospital between 1915 and 1929, Evensen (1936) found that 23% of the patients were self-supportive or in social remission. This was a modest improvement to his own and also to Kraepelin's earlier figures. Similar to Kraepelin's are Langfeldt's (1937) figures based on a seven- to 13-year follow-up study of 100 schizophrenic patients. In his sample, 66% were uncured or worse (just 4% less than in Kraepelin's) and 17% were completely recovered. When this 17% was broken down further, however, 14% consisted of patients with an atypical--so-called schizophreni- form--clinical picture. Taking off the 14% of patients with schizophreniform psychoses leaves 3% full remission, which is only slightly lower than Kraepelin's figure (Hoenig 1967).
The observation that schizophrenic disorders do not always follow an unfavorable course led Langfeldt (1937, 1939, 1956, 1960, 1969) to the identification of criteria which could distinguish between a bona fide "process schizophrenia" with a bad prognosis and "schizophreniform psychoses" with a good prognosis. This separation has been substantiated by the work of Stephens, Shaffer and Carpenter (1982) and Vaillant (1964).
Recognition that schizophrenic disorders do not always follow a deteriorating course led to the distinction between schizophrenic and schizophreniform psychoses by Langfeldt (1939, 1956). Recognition that schizophrenic disorders do not always follow a similar course led to the differentiation of continuous schizophrenia, periodical (recurrent) schizophrenia and shiftlike progressive schizophrenia by Snezhnewski (Nadzharow 1967; Snezhnewski and Vartanian 1971).
Langfeldt's and Snezhnewski's contributions are based on a three dimensional model of schizophrenia with careful consideration to the first three developmental stages. Most recently, Crow (1980) on pragmatic grounds but with consideration to findings in clinical psychopharmacology and brain imaging, proposed that distinction should be made within the schizophrenias between a Type I syndrome, characterized by positive symptoms, i.e., abnormal psychological features such as delusions, hallucinations and thought disorder, and a Type II syndrome, characterized by negative symptoms, i.e., diminished or absent normal functions, such as flattening of affect, poverty of speech and loss of volition.
It should be noted that Kraepelin (1919), who developed the concept of schizophrenia by pooling together a number of different clinical syndromes on the basis of their time course, was not unaware of the heterogeneity within the schizophrenic population. He distinguished among nine different end-states of the disease, ranging from severe deterioration with flattened affect, through prevailing confusion of speech, complex hallucinatory experiences or systematized delusions to mild, nonspecific impairment, or full remission (see Appendix VIII, Table I).
The most important contribution to our understanding of these heterogenous end-states of "schizophrenia" are those of Kleist (1923, 1960) and Leonhard (1957, 1979). In the course of a four dimensional analyses of psychopathological symptoms, course of illness and outcome pictures in a large number of schizophrenic patients, both Kleist and Leonhard have concluded that schizophrenia consists of two distinct populations (groups of disorders) referred to as typical (Kleist) or systematic (Leonhard) and atypical or nonsystematic, and that, each population consists of a number of different illnesses, which have different end-states (subtypes).
The two populations, but not the different end-states, are easily distinguishable on the basis of the course of the schizophrenic process. In the nonsystematic schizophrenias, the intermittent periodicity resembles manic depressive illness, and in the systematic schizophrenias, the "down-hill" course resembles organic dementias. Since Kleist (1960) believed that each subtype is the result of a specific impairment in a different neurological system, he asserted that the schizophrenias are diseases of the brain which may affect several different neurological systems (atypical), or are confined (localized) to one neurological system (typical) (Table XII). Leonhard, on the other hand, emphasized possible genetic differences among the subtypes, and the functional rather than the morphological nature of the various disorders (Table XIII).
There was little, if any, interest in this complex classification of schizophrenias prior to, and immediately following, the introduction of neuroleptics. Prior to, this was probably due to the lack of effective treatment, while after the introduction of neuroleptics it was probably due to the belief that neuroleptics are the treatment of choice for all schizophrenics. With the recognition that not every schizophrenic benefits equally well from neuroleptics and that long-term neuroleptic administration may induce serious adverse effects such as tardive dyskinesia, skin pigmentation and ocular changes, there has been a resurgence of interest in Leonhard's classification of chronic schizophrenias (Ban 1982).
Much impetus for the revival was attributed to Fish (1958a,b, 1962, 1964a,b) who classified a chronic schizophrenic population on the basis of Leonhard's criteria. He found the subtypes to be of clinical relevance and useful in the identification of patients therapeutically responsive to neuroleptics. Further interest in Leonhard's system was generated by Astrup (1959, 1962, 1979). He employed a special test battery, consisting of word associations, motor-conditional reflex, defensive finger withdrawal and several other tests, and was able to identify differences in performance and in level of deterioration among different subtypes of schizophrenia. Furthermore, Ey (1958, 1959) in France and Sarro Burbano (1957) in Spain found no difficulties in employing Leonhard's classification in their patients.
However important Leonhard's classification is, it is difficult to apply because of the practical problems involved in using a complicated system. In an effort to simplify the task, Fish (1964b) devised a guide for the assignment of patients to specific subtypes. Recently another guide has been developed by Ban (1982).
Fberuary 12, 2025