Psychopharmacology and the Classification of Functional Psychoses 

By Thomas A. Ban and Bertalan Pethö

Four-Dimensional Classification

Affective Psychoses

Schizophrenic Psychoses

Nonsystematic Schizophrenias

In his monograph on the Classification of Endogenous Psychoses, Leonhard (1957, 1979) asserts that the nonsystematic schizophrenias are one of the five major groups of disorders within the endogenous psychoses and that "systematic and nonsystematic schizophrenias have essentially nothing to do with each other." In contrast to the systematic schizophrenias which show no polarity, systematic schizophrenias are bipolar disorders which share common features with the cycloid psychoses, a group of bipolar disorders perceived by Leonhard as being on the continuum between the phasic-affective type of psychoses and the schizophrenic type of psychoses.

Nonsystematic schizophrenias consist of three distinct disorders: cataphasia, affect-laden paraphrenia and periodic catatonia. In cataphasia, also referred to as schizophasia, there is a striking dissociation between the disordered or confused speech and thought, and the well-preserved behavior with an appropriate affective response (Kleist and Schwab 1950). The clinical picture is analogous to schizophasia described independently by Kraepelin (1913) and Kleist (1930, 1939).

Kraepelin pointed out a severe confusion of linguistic expressions despite well ordered behavior, while Kleist emphasized the presence of neologisms and word-confusion, which rarely appear in Kraepelin's description. Thus, in patients with cataphasia behavior is characteristically more coherent than speech and responses to questions more understandable than spontaneous speech production. While some patients with cataphasia may display agitation, pressure of speech, confusion, asyntaxis, paralogia, paragrammatism and/or neologisms, other patients may be taciturn and mute and exhibit a dull and empty facial expression. Depending on the prevailing manifestations cataphasia is subtyped into an excited and an inhibited form.

In affect-laden paraphrenia, which corresponds with Kraepelin's (1919) paraphrenia systematica and Kleist's (1947, 1957) progressive reference psychosis, pathology of affectivity plays a central role. Delusions or disorder of thought content are secondary to the pathologically-changed affect.

Verbalization of the delusional material may lead to irritability, enthusiasm, or, in some cases, to threatening verbal, attitudinal or physical behavior. Thus, in contradistinction to cataphasia, in affect-laden paraphrenia there are primary affective changes (anxiety, irritability, ecstasy) and secondary delusions (reference, grandeur, fantastic, mixed) with a paralogical (or logical) systematized (or nonsystematized) delusional structure. Pathognomonic of affect-laden paraphrenia is the fluctuating affective state with emotionally charged delusions, i.e., strong delusional dynamics. Prevailing manifestations are anxiety, irritability, delusions of reference and fantastic delusions; or ecstatic mood and grandiose delusions; or a fluctuating affective state with mixed delusions. Depending on the prevailing clinical features affect-laden paraphrenia is subtyped into an anxious, an ecstatic and a bipolar form.

In periodic catatonia, the third disorder of nonsystematic schizophrenias, motor behavior is primarily disturbed. There is an unusual mixture of excitatory and inhibitory symptoms, associated with episodic hyperkinesia or hypokinesia. In extreme cases there is akinetic stupor. Characteristically there is a decrease or increase of expressive and/or reactive movements with a loss of harmony of natural movements. Other manifestations include parakinesis, motor and postural stereotypy, impulsive acts, negativism, hyperkinesia, hypokinesia, akinesia and/or mixed kinesia. Depending on the prevailing clinical features periodic catatonia is subtyped into an excited, an inhibited and a mixed form.

There is a strong similarity between the three disorders of nonsystematic schizophrenia and cycloid psychoses; cataphasia resembling confusion psychosis, affect-laden paraphrenia resembling anxiety-elation psychosis and periodic catatonia resembling motility psychosis. The signal difference between the two groups of disorders is related to outcome with full recovery in cycloid psychoses and residual symptoms in the nonsystematic schizophrenias (Ban, Guy and Wilson 1984a).

 Without distinguishing between the groups of nonsystematic and systematic schizophrenias. Within this all embracing group of disorders there are ten different types of schizophrenic illnesses described. Of these ten types, there is some correspondence between the simple and hebephrenic types of ICD-9 and the hebephrenic category of Leonhard; the catatonic type of ICD-9 and the catatonic category including periodic catatonia of Leonhard; the paranoid type of ICD-9 and the paraphrenic category of Leonhard; schizoaffective type of ICD-9 and affect-laden paraphrenia of Leonhard. While Leonhard's classification has no corresponding diagnoses for latent schizophrenia, residual schizophrenia, other schizophrenia and unspecified schizophrenia, ICD-9 has no corresponding diagnoses for cataphasia and for any one of the 16 subtypes of systematic schizophrenia (which are adapted in the DCR).

Similar to ICD-9, in DSM-III also, all schizophrenic psychoses are grouped under schizophrenic disorders without distinguishing between the groups of nonsystematic and systematic schizophrenias. In contradistinction to ICD-9, however, within this all embracing group of disorders there are only five different types of schizophrenic illnesses. Of these five types, there is some correspondence between the disorganized type of DSM-III and hebephrenic category of Leonhard; catatonic type of DSM-III and catatonic category, including periodic catatonia of Leonhard; and paranoid type of DSM-III and paraphrenic category including affect-laden paraphrenia of Leonhard. While Leonhard's classification has no corresponding diagnoses for the undifferentiated and residual type, DSM-III has no corresponding diagnoses for cataphasia and for anyone of the 16 subtypes of systematic schizophrenia.