Thomas: A Ban: In historical perspective Peralta, Cuesta and their associates’ findings on the highest familiality of Leonhard’s classification in polynosologic study

 Comment by Per Bech
 

The major issue in Tom Ban’s essay is Leonhard’s attempt to subdivide Kraepelin’s diagnosis of schizophrenia into unsystematic versus systematic schizophrenia. Kraepelin’s clinical concept of schizophrenia included a purely descriptive approach without any reference to the genesis of schizophrenia. He observed that an autistic withdrawal from the surroundings often presented in schizophrenia patients years before the outbreak of disease. This, he noticed, was also a common phenomenon in the final residual states of the disease (Dein 1966). In his own study on 142 patients with “dementia praecox”, or Kraepelin schizophrenia, and 52 patients with schizophreniform disorder, Dein (1964) found that 89% in the schizophrenia group had pre-autistic disturbances but only 29% in the group with schizophreniform disorder (Χ²  = 12.1, P < 0.001).When focusing on the duration and severity of the pre-autistic disturbances, Dein (1964) identified 109 of the 142 schizophrenic patients (77%) but only 1 patient among the 52 schizophreniform patients (2%).  In contrast, Schneider (1955) found no pre-autistic disturbances in his patients. Actually, Schneider considered schizophrenia as an acute onset disorder and therefore a “somatic” disorder.

Moreover, Schneider (1955) considered his first rank symptoms to be of diagnostic significance in schizophrenia, although he added that these symptoms need not always be present in the disorder. Schneider’s first rank symptoms are included in both DSM-III and DSM-IV as well as in ICD-10. However, in DSM-5 they are deleted. In summary, systematic Kraepelin schizophrenia was first accepted with DSM-5. Schneider’s schizophrenia is to be considered as unsystematic schizophrenia.

When comparing Kraepelin’s original 53 cases of dementia praecox, or schizophrenia, with the Present State Examination (PSE) diagnostic system, which includes the first-rank symptoms as a major diagnostic element, Jablensky et al (1993) found that Kraepelin’s concept of schizophrenia was much narrower than the Schneiderian concept. Actually, only two of Kraepelin’s patients fulfilled the criteria of Schneider’s full first-rank syndrome.

The antipsychotic effect of chlorpromazine focuses on the three “psychotic” symptoms in the DSM-5 syndrome of schizophrenia (delusions, hallucinations, and disorganized thinking). The pure schizophrenia symptoms of blunted or incongruous affect, withdrawal, and lack of flow in conversation, the Kraepelin symptoms, are not reached by chlorpromazine. The findings by Peralta et al (2015): that Leonhard’s systematic schizophrenia had more familial loadings than DSM-IV and ICD-10 with their Schneiderian concept of schizophrenia is therefore very important. It was really a good decision to exclude the Schneiderian first rank symptoms for schizophrenia in the DSM-5.

Concerning the Peralta et al (2015) results on Leonhard’s affective psychoses, I was indeed very surprised to find not a single reference to the studies made by Carlo Perris (1928 – 2000). Perris performed his classical studies on bipolar (manic-depressive) and unipolar recurrent depressive psychosis based on Leonhard’s classification. Perris’ genetic investigation (Perris 1966) confirmed Leonhard’s observation that the overall heredity of psychoses was greater in bipolar and unipolar probands. Manic probands were found closer to the bipolar than the unipolar probands. In total 138 bipolar and 139 unipolar psychoses were investigated. In his follow-up study, Perris (1968) demonstrated that when using the operational criterion of at least three consecutive depressive episodes in order to classify unipolar recurrent depressive disorder (as Perris did in his Leonhard-related study) the risk of diagnostic error for bipolar disorder will not exceed 16 percent. Currently, we use the criterion of 5 consecutive depressive episodes for unipolar recurrent depression (Perlis et al. 2006).

Leonhard’s classification is certainly the last based exclusively on psychopathology. It confirms Kraepelin’s concept of schizophrenia and introduces the important concept of bipolarity.

REFERENCES

Dein E. On the concept of autism. Acta Psychiatrica Scandinavica 1966; 191: 124-35.

Dein E. Personlighedstyper ved skizofreni og skizofreniforme psykoser (personality types in schizophrenia and schizophreniform psychosis). Nordic Journal of Psychiatry 1964; 18: 88-105.

Jablensky A, Hugler H, Von Cranach M, Kalinov K. Kraepelin revisited: A reassessment and statistical analysis of dementia praecox and manic-depressive insanity in 1908. Psychological Medicine 1993; 23: 843-58.

Peralta V, Goldberg X, Ribeiro M, Sanchez-Torres AM, Fananas L, Cuesta MJ. Familiality of psychotic disorders: A polynosologic study in multiplex families. Schizophrenia Bulletin 2015;.

Perlis RH, Ostacher MJ, Patel JK, Marangell LB, Zhang H, Wisniewski SR, Ketter TA, Miklowitz DJ, Otto MW, Gyulai L, Reilly-Harrington NA, Nierenberg AA, Sachs GS, Thase ME. Predictors of recurrence in bipolar disorder: Primary outcomes from the systematic treatment enhancement program for bipolar disorder (STEP-BD). The American Journal of Psychiatry 2006; 163: 217-24.

Perris C. The course of depressive psychoses. Acta Psychiatrica Scandinavica 1968; 44: 238-48.

Perris C. A study of bipolar (manic-depressive) and unipolar recurrent depressive psychoses. I. genetic investigation. Acta Psychiatrica Scandinavica.Supplementum 1966; 194: 15-44.

Schneider K. Klinische psychopathologie. Stuttgart: Thieme; 1955.

 Per Bech

June 2, 2016