From the dichotomy to a three-part grouping of endogenous psychoses
By Ernst J. Franzek
One of the main reasons for the dragging progress in psychoses research is the differing standpoint of leading psychiatrists when classifying psychoses which exhibit “First Rank” Symptoms according to Kurt Schneider (1957, 1959). For more than two centuries, psychiatrists and scientists have been intensively searching for a valid classification system of mental disorders which would serve as a basis for treatment strategies and etiological research. Again, and again, concepts have been replaced. As soon as a classification system caused difficulties and inconsistencies with the clinical praxis it was often changed and/or replaced completely. However, positive achievements were also left behind and even highly valuable theories and concepts sometimes completely vanished into oblivion. For example, the still modern looking brain morphological concept of Wernicke(1900) was poorly accepted by his contemporaries and waved aside as brain mythology. No one listened to the judgment of the important psychopathologist, Jaspers, who stated at that time that Wernicke created the most important and brilliantly thought-out work in Psychiatry (Jaspers 1973).
Bleuler (1911) introduced the term schizophrenia in place of “Dementia praecox” in order to enable a better communication between psychiatrists, but it was not his intention to abolish the prognostic assessment that Kraepelin (1896) associated with the concept of Dementia praecox. Kurt Schneider (1959) created, with his concept of first and second rank symptoms, a brilliant possibility to differentiate reliably between disorders of the affective and schizophrenic spectrum. Unfortunately, from then on, the diagnosis of schizophrenia was without any statement about the long-term course and the prognosis of the disease.
The aim of the currently used operational diagnostic approach is to reach as high as possible reliability of diagnoses between different psychiatrists and researchers. This should improve the communication between different research groups and better the comparison of study results. The aim of a high reliability has surely been reached. However, the expected striking progress in research and clinical praxis has failed to materialize. There is still a long way to go and the development is nowhere near finished (Klosterkötter 1999). In research, we have often conflicting findings and only few results become generally accepted at once. The high reliability that has been reached obviously does not provide the “kings road.” Reliability, which means agreement, does not simultaneously mean validity (Gottesman and Shields 1982). Several opinion leaders in psychiatry expressed the view that if psychiatric research will not reflect again on its psychopathological roots we will wake up and discover that we face problems. Applying technology without the companionship of wise clinicians with special expertise, research in psychoses will be a sterile and perhaps fruitless enterprise. We have now at our disposal powerful genetic, biochemical and brain-imaging technology. Nevertheless, there is an increasing gap between these developments and the growth in our understanding of the etiology of schizophrenia (Parnas 1991).
One major criticism of the operational diagnostic systems is that they often lead to uncritical thinking about criteria and that they give a diagnostic certainty under false pretenses. The atheoretical claim of these diagnostic systems is often disregarded and the diagnostic categories are falsely taken as disease entities. Furthermore, many symptoms have been completely omitted because of their lacking reliability. The consequences of this approach are that clinical psychopathology is now often reduced to generic terms and does not any more allow bringing out subtle differences of the clinical pictures that we meet in the daily praxis (Sass 1994). Instead of the atheoretical approach an “integrative psychopathology” should be used. The main tasks of this approach should lay on the foundations for cooperation between the various branches of research interested in studying psychiatric issues. Applied integrative psychopathology can then be fruitful for cooperative research and psychiatric clinical practice.
Clinical and empirical-based classifications systems that are highly sophisticated, however, are sometimes very complex so that their use in research and clinical praxis seems to be limited. One example is the classification of the endogenous psychoses according to Leonhard (1957). Despite its high complexity, there are a number of studies that confirm the validity of Leonhard´s classification system (Ban 1990; Beckmann Franzek and Stöber 1996; Franzek and Beckmann 1996; Stöber, Franzek and Beckmann 1994; Perris 1986). In the classification, Leonhard’s concept of cycloid psychosis has been of particular interest.
Many have occupied themselves with these “atypical psychoses” (Perris 1986; Marneros 1999; Beckmann and Franzek 2000; Brockington, Perris, Kendell, Hillier and Wainwright 1982; Brockington, Perris and Meltzer 1982; Cutting, Clare and Mann 1978). About 10 – 20% of all first admissions to a psychiatric hospital are cycloid psychoses (Cutting, Clare and Mann 1978; Zaudig and Vogl 1983). The basis of the ICD-10 category “acute transient psychotic disorders” is Perris’ (1986) and Brockington’s (1982) modified and considerably simplified diagnostic concept of Leonhard’s diagnostic concept of cycloid psychoses. The definition of this ICD-10 category corresponds partly with the French concept of “Bouffée delirante,” as well as with the Scandinavian concept of “psychogenic psychoses.” However, a body of research is pointing out that a narrowing, as well as widening, of the original concept of cycloid psychoses can lead to a substantial loss of validity (Beckmann and Franzek 2000; Franzek, Becker, Hofmann, Flöhl, Stöber and 1996; Franzek and Beckmann 1999).
The diagnosis of a psychosis outside the cycloid spectrum is possible with operationalized criteria based on the original concept of Leonhard (1957). This includes the reliable differentiation of cycloid psychoses from the spectrum of pure affective disorders, on the one hand, and from the spectrum of core schizophrenic disorders on the other hand. In Table 1 the operational diagnostic criteria for cycloid psychoses are provided. The symptom order is hierarchical, i.e., without the presence of one of three obligatory symptoms the diagnosis of a cycloid psychosis is not allowed to be made. This is the main difference between DSM and ICD where there is no demand for an obligatory symptom in order to establish a diagnosis. On the other hand, the occurrence of special symptoms, such as clear delusions of being controlled or influenced by others; or the clear occurrence of voices that comment on the patients’ thoughts or behaviors or talk about the patient as a third person; as well as absurd and bizarre delusions exclude the diagnosis of a cycloid psychosis. If these kinds of symptoms are unequivocally present, the diagnosis of schizophrenia has to be made (Table 1).
Table 1. Diagnostic criteria of the stress-induced cycloid psychoses
Acute psychotic state occurring for the first time in patients from 15 to 60 years old with a sudden onset and rapid change from a healthy to a complete psychotic state within one to four weeks. Often precedes a longer period of exogenous or endogenous stress (i.e. giving birth, psychosocial stress during work or in relationships, drug use, etc.).
At least one of the following symptoms is required (obligatory):
- Extreme anxiety accompanied by delusions of reference, by delusional perceptions and/or
delusions of persecution or ecstatic affect accompanied by ideas of calling, of being able to bring salvation for others
- Excitation of the thought process with pressure of speech and incoherence or inhibition of
the thought process to the extreme of mutism and stupor
- Increase of spontaneous, involuntary movements to the extreme of senseless hyperkinesia
or inhibition to complete lack of spontaneous, involuntary and voluntary movements to the extreme of catatonic stupor
Accessory symptoms (very often present but not obligatory):
1. Hallucinations on different sense-organs
3. Transitory misidentification of persons and delusional perceptions
4. Somatic misperceptions with anxiety
5. Special interest in dead and life after death
7. Thought insertion, thought withdrawal, thought spreading
Symptoms which exclude the diagnosis of a cycloid psychoses:
1. Delusions of control, influence, or passivity, clearly referred to body or limb
movements or specific thoughts, actions, sensations or perceptions
2. Hallucinatory voices giving a running commentary on the patient´s behavior
or discussing the patient among themselves
3. Persistent delusions of other kinds that are culturally inappropriate and
completely impossible, contradicting valid laws of biology and nature
The polymorphous symptomatology can change within one psychotic episode and the clinical picture often exhibits a bipolar structure. There is a strong tendency for a recurrent course. However, every psychotic episode is remitting (no time criteria!) and no positive or primary negative schizophrenic symptoms persist in the long run.
The course of cycloid psychoses is usually remittent; acute psychotic episodes are followed by healthy intervals without residual psychopathology. Sometimes there is only one psychotic episode during the whole life. However, if multiple psychotic episodes have occurred, the stress tolerance of the patients can be extremely reduced and little stressors can immediately trigger a new acute psychotic episode. Stress factors can be exogenous as well as endogenous. It was found that giving birth to a child, psychosocial stress during work or in relationships, as well as cocaine- and cannabis use can provoke or trigger an acute episode of a cycloid psychosis (Stöber Franzek and Beckmann 1994; Beckmann and Franzek 2000; Franzek and Beckmann 1999: Pfuhlmann, Jabs, Althaus, Schmidtke, Bartsch, Stöber, Beckmann and Franzek 2004). The term “stress induced psychosis” can almost always be applied to this kind of psychoses. In contrast to psychoses of the manic depressive and the schizophrenic spectrum of psychoses, the vertical genetic loading (= genetic loading through generations) was found to be low, with only little differences compared to the normal population. However, a body of research points to a disruption of prenatal neurodevelopment that can predispose to a stress induced cycloid psychosis later in life (Franzek and Beckmann 1996; Beckmann and Franzek 2000; Franzek, Becker, Hofmann, Flöhl, Stöber and Beckmann 1996; Franzek and Beckmann 1999; Pfuhlmann, Jabs, Althaus, Schmidtke, Bartsch, Stöber, Beckmann and Franzek 2004; Stöber, Kocher, Franzek and Beckmann 1997; Strik, Fallgatter, Stöber, Franzek and Beckmann 1996; Supprian, Bengel, Hofmann, Fallgatter and Franzek 2000).
Preview on future developments
An outstanding milestone in psychosis research set without any doubt Kraepelin´s prognostic dichotomy of the endogenous psychoses in the manic-depressive spectrum and the “endogenous insanities,” under which he subsumed “dementia praecox.” Also, the initiation of the modern operationalized diagnostic systems by the use of Kurt Schneider´s criteria of schizophrenia has been of great significance. The concept of cycloid psychosis based on Kleist´s and Leonhard’s ideas seems to be very promising for the future. Because of their good prognosis in the long-term course, Kraepelin would have included them in the manic-depressive spectrum, whereas Bleuler and Schneider would have said they belong to the group of schizophrenias because of frequently occurring “typical schizophrenic symptoms.” However, new twin and family studies show that these disorders can neither be integrated into the bipolar affective spectrum nor is the allocation to the genetic spectrum of schizophrenic disorders successful. The label “stress induced psychoses” applies particularly to the cycloid psychoses in the acute beginning and to the appearance of recurrences.
A replacement and possible extension of Kraepelin’s conceptual dichotomy of “endogenous psychoses” by dividing (“partitioning”) the psychoses into three groups, an affective (bipolar) spectrum of psychoses, a spectrum of stress induced cycloid psychoses and a spectrum of schizophrenic psychoses, could set new impulses for research and clinical praxis. In this context, a serious scientific discussion of apparently conflictive positions seems to be necessary. Probably the combination and integration of diagnostic approaches, which so far appear mutually exclusive, will drive the research forward again. We expect a new dynamic in research and praxis and new insights in the puzzle of psychotic disorders. We do not need dogmatic paradigms but clinical realities.
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December 21, 2017