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In this paper the author highlights the importance that the classificatory work carried out by Leonhard has had for recent international developments in the classification of mental disorders. In particular, the diagnostic relevance of a distinction between bipolar and unipolar affective disorders and the separation of the cycloid psychotic disorders from other major psychoses is underscored.
Psychiatric diagnoses in endogenous psychoses are still largely based on clinical psychopathology. Despite intensive efforts including progress to more reliability in classification, no definite and causally relevant biological abnormalities have been identified so far. This failure might be due to the present standard classification systems like DSM or ICD being too crude to allow the distinction of homogeneous nosological entities. The classification developed by K. Leonhard offers a more subtle alternative. In order to facilitate the handling of this system and in the interest of reliability, an algorithm for computer-assisted diagnostic decision making based on similarities to Leonhard's ideal types is presented.
Of a large sample of patients with paranoid psychoses consecutively admitted to the Psychiatric Department, University of Oslo, during a period after World War II, 10 patients (6.3%, 9 women and 1 man) became ill through accusations of unpatriotic conduct during the war. The psychosis seemed precipitated in connection with legal procedures against the patient in 3 cases, and against close relatives in 2 patients. In 2 cases mixed precipitating events were present, while the psychosis in 3 cases had a connection with the woman being intimate with occupation soldiers. Discharge diagnosis according to DSM-III was schizophrenia (n = 2), schizophreniform disorder (n = 4), schizoaffective disorder (n = 1), major depressive disorder (n = 1), mania (n = 1), and atypical psychosis (n = 1). The patients have been followed up twice, with a mean 31 years of observation. Course and outcome varied, mostly according to the diagnosis. Most patients had a favorable global outcome, although they had a tendency to keep up their social isolation. None of the patients felt they had done anything wrong or regretted their behavior during the war.
200 first admissions with functional psychoses were interviewed with PSE and rated simultaneously according to different diagnostic criteria (ICD-9, RDC, DSM-III, St. Louis, Taylor, Vienna Research Criteria). At follow-up 7 years later 186 patients could be traced and a course diagnosis was applied to each patient. Temporal stability of diagnostic criteria was calculated for ICD-9, RDC and DSM-III by stability coefficient and kappa values and was used as a criterion for validity. Schizophrenia and affective disorder display considerable stability over time, no matter whether one uses ICD-9, RDC or DSM-III. The data for schizoaffective disorder are less impressive, the stability coefficient is much higher for schizoaffective bipolar than for schizoaffective depressive patients.
Traditional explanatory models, based on core psychological deficits, vulnerability-stress models or distinctions between negative and positive symptoms, may not be sufficient to understand the phenomenon of chronicity. This linear thinking, looking for monocausal explanations, should be replaced by exploring multicausal and circular processes over time, including the individual ecological context of a given patient. Thus, chronicity appears to result much more from endless loops and irreversible bifurcations in its dynamics over time than to be a stable state. Furthermore, the current views on psychopathology and prognosis need to be fundamentally reexamined in the light of this new way of thinking. For understanding and treatment of chronic psychoses, this ecological perspective implies programs which do not focus only on the patient, but look for 'ecological niches' and interventions favoring synergetics and self-organization within the social networks and at the worksite of a given patient. A recently implemented five-step program for vocational rehabilitation and the corresponding research plan will be presented and discussed.
Among the existing classifications in the field of psychiatry, Leonhard's comprises 35 forms of endogenous psychoses, allowing a more precise differentiation. Computerassisted mathematical methods of numerical taxonomy, frequently used in other fields of biological sciences, were used to check its coherence, definitely proving its taxonomic validity. Numerical values were assigned to signs and symptoms described by Leonhard, taking into account their frequency and diagnostical importance. The resulting data matrix was processed, obtaining the dissimilitude coefficients and the main components which validate Leonhard classification. This method can be applied to other psychiatric classifications validating them or displaying their weaknesses.
The authors examined central catecholamine metabolism in various symptomatological psychotic disorders and the relationship between the biochemical and therapeutic action profiles of neuroleptics. Haloperidol and (to a lesser entent) chlorpromaziner icrease the dopamine (DA) turnover in the central nervous system, but the authors influenced; oxypertine has the reverse effect. The authors question whether disorders of DA-metabolism underlie or result from disorders of motor activity, postulating that the hyperdopaminergic activity observable in psychoses is dependent on motor hyperactivity rather than on "true" or psychotic symptoms such as delusions and hallucinations.
In this double-blind study dihydrotachysterol (DHT) was given orally to eight psychotic patients; in each case marked increases in psychosis and agitation accompanied increases in serum calcium and phosphorus within two weeks after active drug was substituted for placebo. In the three patients whose psychoses exhibited periodic spontaneous exacerbations, the agitated episodes grew more severe. Serum creatine phosphokinase (CPK) increased in all but one patient. By contrast, when three periodically psychotic patients received synthetic salmon calcitonin (SCT), the severity and frequency of agitated episodes decreased while CSF calcium increased in all three. These data support the hypothesis that the observed abrupt increases in serum calcium and phosphorus might cause the opposite CSF calcium shifts, the behavioral agitation and the increases in serum CPK frequently noted during acute psychosis.
The three most widely used diagnostic systems in American psychiatry--the Feighner criteria, the Research Diagnostic Criteria, and DSM-III--appeared sequentially at 4-year intervals. The fact that the latter two systems each incorporated changes in essentially all diagnostic categories implied progress toward greater validity; however, this assumption has rarely been tested directly. To do this, the authors applied each of these three systems to 98 consecutively admitted patients with nonmanic psychoses. Although family history and 6-month follow-up data strongly supported the validity of diagnostic distinctions made in each of the three systems, they did not show increments in validity with successively developed criteria sets.
The mental concept of puerperal psychoses is considered as having important determinants in body image disturbances. A case is presented of a woman who had had postpartum psychiatric disorders after the birth of each of her two daughters, and who suffered a relapse in identification with her parturient younger daughter.
The authors examined the reports of MRI brain studies of 69 patients with DSM-III-R-diagnosed psychotic disorders (30 early-onset and 24 late-onset schizophrenia patients and 15 with other psychoses) and 41 normal comparison subjects. Participants' ages ranged from 45 to 87 years. A qualitative rating scheme determined type and severity of clinically detectable abnormalities, including volume loss, infarcts, lacunae, and white matter hyperintensities. In this clinically well-characterized sample, the vast majority of the MRIs were within normal limits. There were no significant differences between psychosis patients and normal comparison subjects or between early-onset and late-onset schizophrenia patients in frequency, type, or severity of gross structural abnormalities. The results indicate that late-onset schizophrenia and related disorders can exist without clinically significant gross structural abnormalities in the brain.
Little is known about the primary cause of mental illness but in a major area of psychiatry effective secondary prevention has been developed. Potent psychopharmacological agents have become available to the clinical psychiatrist and it has been shown that the prognosis in the psychoses can be significantly improved when continuous drug treatment is prescribed. As treatment has to be given for years the psychiatric clinic has become committed to a potentially large group of patients whose mental wellbeing is dependent upon regular psychotropic medication.
A review of the case books of 868 patients who had been admitted into a psychiatric hospital from January 1, 1970, to December 31, 1973, was carried out for consistency in the pattern of diagnosis by the same or different psychiatrists. Of these, 16.5% had a revision in diagnosis. The pertinent literature was reviewed. The possible factors that contribute to the observed inconsistency in diagnosis in this and other investigations are discussed. It is concluded that the problems as reflected in the significant change in diagnosis in this study are multifactorial. It is suggested that these problems may be related to the unknown etiology of the functional psychoses and the absence of identifiable specific lesions.
Monosymptomatic hypochondriacal psychoses are akin to paranoia. Although presenting with a variety of delusional complaints in individual cases, the condition appears to represent a relatively dis crete diagnostic entity. It is less rare than usually thought, but those afflicted frequently to to the physical specialties, whose treatment does not benefit them. It is important to recognize the illness, since there is tentative evidence that it may respond to treatment with pimozide.
A comparison was made of the social and domestic background, prepsychotic personality and symptomatology of deaf ('hard of hearing') and non-deaf patients aged 50 or over with paranoid or affective psychoses. The deaf patients were found to be a very heterogeneous group in respect of age of onset, duration, severity and pathological basis of their deafness, but there was a substantial subgroup of paranoid patients with deafness beginning before the age of 45 in whom the personality appeared to have been less deviating than in the remainder. It was thought that the deafness in this subgroup had possibly played a relatively specific role in causing the psychosis. Some problems in identifying deafness and assessing its significance are discussed.
The mode of inheritance of affective psychoses was studied in 800 first degree and 582 second degree relatives of 122 probands. Morbidity risk for unipolar depression was 12.0+/-3.2 and 11.4+/-2.7 per cent respectively for parents and siblings of probands suffering from unipolar depression. Morbidity risk for manic-depressive psychosis for the respective groups of first degree relatives of manic-depressive probands was 15.1+/-3.2 and 16.9+/-3.2 per cent. In second degree relatives the morbidity risk was 3.4+/-1.0 and 5.3+/-1.4 per cent for unipolar depression and manic-depressive psychosis respectively. The results indicate the role of genetical factors in the etiology of both types of affective disorder and show that unipolar depression and manic-depressive psychosis are distinct entities. The hypothesis of X-linked dominant transmission was not confirmed in either of these affective disorders. By means of the computational model of Slater, no results compatible with a polygenic inheritance of unipolar depression or manic-depressive psychosis were found.
A method is described for identifying a genuine boundary between related syndromes, if one exists, by demonstrating a non-linear relationship between symptomatology and outcome. The technique was applied to the putative boundary between schizophrenic and affective psychoses, but a non-linear relationship could not be demonstrated.
Computerized axial tomography (CAT) scanning was carried out on 57 patients who had received a hospital diagnosis of psychoses associated with epilepsy, and 78 epileptic patients with psychiatric illness other than epilepsy. Abnormal scans were reported in approximately half of the cases in both groups. An excess of left hemisphere abnormality was noted in the psychotic group, but this was not significant. These findings failed to provide firm support for the hypothesis that lateralized structural damage to the cerebral hemispheres plays a major part in determining the specific pattern of associated psychotic illness.