Psychopharmacology and the Classification of Functional Psychoses
By Thomas A. Ban and Bertalan Pethö
CONCLUSIONS
In this monograph the historical development of a four-dimensional classification of functional psychoses was outlined. The presentation was restricted to the evolution of concepts with emphasis on the extension of the diagnostic information from cross-sectional psychopathology to all developmental stages of psychiatric illness.
The proposed classification is firmly rooted in cross-sectional psychopathological symptoms. It differs from syndromatological classifications in that the clinical syndromes are not studied in isolation but in the nosological context of the total longitudinal picture of the illness. The nosological entities described do not fulfill all the criteria of a "disease" (Jaspers, 1959, 1963). However, a nosological approach was employed to prevent confounding the biological correlates of any particular stage (cross-sectional syndrome) of a disease with the central biological mechanism of the illness.
Inclusion of "psychogenic" psychoses (Faergeman, 1963) represents an extension of the original concept of functional psychoses from exclusively "productive" (endogenous) to "reactive" illnesses. In "productive" illness, "a process takes its course, leading to a progressive alteration in the psychic constitution," without external cause. In "reactive" illness, "a preexisting abnormal constitution reacts in an abnormal way to external events only to revert to its earlier state when these events cease" (Hoenig, 1984). However, the fact remains that even in case of psychogenic (reactive) psychoses only "the contents of the pathological states are meaningfully connected with the initial experience" (Jaspers, 1913, 1974). In other words, understanding these disorders on the basis of a traumatic life event relates to the content of these psychoses but does not extend to understanding their forms.
The adoption of Leonhard's (1957) subtypes in the classification of "endogenous-productive" illnesses is based primarily on clinical observations. In favor that the subtypes are valid diagnoses are the findings that in their course functional psychoses display increasingly differentiated features. This is at variance with Conrad's (1958) contention that progressive stages of one and the same illness are represented in the different syndromes (Fish, 1961). None of these observations exclude the possibility that a state of over-arousal (Kornetsky and Mirsky, 1966; Weil-Melherbe and Szara, 1971) might play a central role in the pathophysiology of all subtypes or developmental stages of schizophrenias and desynchronization of the circadian rhythm (Halberg, 1968; Mellerup and Rafaelsen, 1979; Pflug and Tolle, 1971) of all affective disorders General paralysis, a disease produced by the effects of treponema pallidum on the brain, may appear as several distinctly different syndromes. Because of this, general paralysis has become a specter against "subtyping" in psychiatry. Within a three-dimensional model of diagnosis all patients with the same diagnosis and regardless of their early manifestations, display, a similar syndrome, i.e., dementia. In other words, it is dedifferentiation which results in dementia, the common final syndrome in all patients with general paralysis, a systemic neurological disease; while it is differentiation which results in subtypes, or distinct syndromes in patients with functional psychoses. Consequently, diagnostic evaluation of these disorders must proceed in a stepwise fashion and encounter an increasingly larger proportion of the illness, i.e., onset, cross-sectional syndrome, course and outcome.
Description of psychopathological symptoms is usually the first step in diagnostic evaluation. This is followed by the identification of "psychosyndromes" which are based on the profiles of simultaneously present psychopathological forms. Considering that localization of psychopathological events (symptoms) in the brain has failed in spite of many attempts, a purely syndrome-based approach to classification of psychiatric disorders has little to offer concerning an understanding of these illnesses.
An alternative to the syndrome based approach to the classification of psychiatric disorders is the nosology based approach. By accepting the "nosological postulate" it is assumed that each psychiatric illness, characterized by a specific psychopathologic syndrome, has a characteristic course with a predictable outcome even if, for the time being, its etiology is not known.