Edward Shorter’s comment 
Ernst Franzek: From the dichotomy to a three-part grouping of endogenous psychoses

It was the "Würzburg School" that basically took over the management of Karl Leonhard's 1957 diagnostic system.  Leonhard was trying to break the great monolith of "schizophrenia" into disease entities that corresponded more closely to what patients had in nature.   After Leonhard's death in 1988, Helmut Beckmann, who held the Psychiatry chair in Würzburg, became the main acolyte.  With Beckmann's own recent death, that mantle has now fallen upon the shoulders of his student Ernst Franzek.  Various international authorities join Franzek in the current effort to rehabilitate Leonhard's "cyclical psychoses."

The cyclical psychoses that we find here are rather different from those of Leonhard's original design.  "Cyclical" means moving back and forth -- or up and down -- in clinical presentation, and Leonhard conceived three cyclical psychoses:

(1) the alternation of anxiety and happiness (Angst-Glück Psychose);

(2) "agitated and inhibited confusion" (erregt-gehemmte Verwirrtheit);

(3) "hyperkinetic-akinetic motility psychosis" (hyperkinetische - Motilitätspsychose)

Leonhard insisted that all three cyclical psychoses were precisely that: cyclical.  This is something we miss in Franzek's proposal.  We have the three original Leonhardian cyclical psychoses, but with "or's," suggesting different presentations, or clinical variants, rather than alternation.  Can one have a cyclical psychosis in the absence of alternation?   Still, Franzek gives us half a loaf: for "cyclical psychosis" we still need one of the three Leonhardian types, but they don't have to be cyclical.

So what?  People have walked away from much of Freud's original doctrine on infantile sexuality while still calling themselves "Freudian."  Maybe investigators can walk away from parts of Leonhard's schema and still call themselves "Leonhardian."  That is a scholastic problem.

But in the Franzek proposal there is a real clinical problem as well.  One can only be sympathetic to attempts to break up the great "schizophrenia" colossus that has survived even into DSM-5.  And Franzek's proposal is intriguing:  We'll insert "cyclical psychosis" in between serious (psychotic) mood disorders on the one side and core schizophrenia on the other side.  So, we now have three big psychotic illnesses rather than Kraepelin's original two (which were manic-depressive insanity and dementia praecox).

Cool.  What's the difference among the three?  Cyclical psychosis, says Franzek, is induced by stress; the big mood disorders and core schizophrenia are not necessarily stress-induced.  As Jaspers said, they can come "out of the blue."  As well, in core schizophrenia there is no restitutio ad integrum, no "return to baseline."   In the cyclical psychoses there is.  They are entirely recoverable.

With cyclical psychosis we are starting to get something that looks like bouffée délirante or "psychogenic psychosis":  they are stress induced; they may or may not be relapsing; and they return to baseline.  Franzek points this out.  Why not just stick with bouffée délirante?  Here Franzek shows his colors as Leonhard's student, not Valentin Magnan's (who in 1886 conceived transitory delusional psychosis, or bouffée délirante).  It was Leonhard, not Magnan, who came up with the "cyclic" notion (or rather adopted the cyclic concept of Wernicke and Kleist).

So, what's the clinical problem here?  It's called catatonia.  Anything that "alternates" sounds a lot like catatonia, where the alternation of agitation and stupor is common -- and quite pathognomonic.  In the DSM there is nothing where stupor and agitation alternate.  Leonhard recognized the distinctive nature of this alternation but called it part of "cyclical psychosis."  (For Leonhard, catatonia was something quite different.)

Why are we squabbling about catatonia, whether it's part of one fantastic diagnostic system or another?  There are stakes here, because today we recognize catatonia as eminently treatable; it is unclear to what therapy, if any, Leonhard's cyclical psychoses respond.  (It was, as other investigators established, Leonhard's "unsystematic schizophrenias" -- above all, "affect-laden paraphrenia" -- that responded to neuroleptic treatment.) 

Thus, if you accept catatonia as a disease of its own, you will think clearly of the effective treatments of it.  If you see it buried in some difficult-to-master Central European nosological system, and not even called catatonia, your mind may drift on.

So, what can we say of Franzek's current effort to break up the monolith of schizophrenia?  He gets full marks for trying.  His "cyclical psychoses" seem somewhat arbitrary in concept, as did the original Leonhardian diagnoses themselves.  But no, Franzek responds:  They are stress-induced and remit completely.  Nothing arbitrary about that.  Hmmm, I'd like to see a bit more evidence on this before accepting it as gospel. 

In the meantime, other efforts to break up the nosological monstrosity that Kraepelin conceived in 1893 as dementia praecox and Bleuler perpetuated in 1908 as schizophrenia, are only to be welcomed.

March 15, 2018