Bfm:978-3-7091-6371-9/1.Pdf

Classification of Endogenous Psychoses and their Differentiated Etiology

Second, revised and enlarged edition

Springer-Verlag Wien GmbH Prof. Dr. med. Dr. h. c. Helmut Beckmann Psychiatrische Klinik und Poliklinik, Universit:âts-Nervenklinik, Wiirzburg, Deutschland

Prof. Dr. Karl Leonhardt, Berlin

Translated from German by Charles H. Cahn

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Library of Congress Cataloging-in-Publication Data

Leonhard, Karl, 1904- [Aufteilung der endogenen Psychosen und ihre differenzierte Ătiologie, English] Classification of endogenous psychoses and their differentiated etiology / Karl Leonhard. -- 2nd, rev. and enlarged ed. / edited by He1mut Beckmann. p. cm. Previously published: Classification of endogenous psychoses. New York: Irvington Publishers, 1979. "Originally published as: Aufteilung der endogenen Psychosen und ihre differenzierte Ătiologie, 7. neubearbeitete und ergănzte Auflage. © 1995 Thieme, Stuttgart" -- CIP t.p. verso. Inc1udes bibliographical references and index. ISBN 978-3-7091-7308-4 ISBN 978-3-7091-6371-9 (eBook) DOI 10.1007/978-3-7091-6371-9 1. Psychoses Classification. 1. Beckmann, Helmut, 1940- . II. Leonhard, Karl, 1904-Aufteilung der endogenen Psychosen. English. III. Title. RCS12.L413 1999 616.89'001'2- -dc21

ISBN 978-3-7091-7308-4 Editor's Comment

Half a century ago KOLLE spoke about the "Oracle of Delphi of the Endoge nous Psychoses". Since then in spite of all innovations and technological achievements in the past decades this pronouncement has not lost anything of its significance and its application to the present day research situation. Mental and emotional disorders belong to the large group of"diseases of the people". From the public health point of view they are of extraordinary import for every community. Accordingly, some countries have generously supported research efforts in the neurosciences as well as in the physical sciences with the aim of achieving tangible progress in prevention and pre cise diagnosis, as well as rehabilitation. Such efforts have amongst others led to the declaration of the "Decade of the Brain" in the United States and more recently to that of the "World Decade of the Brain" in which all inter national societies concerned with the problem of mental health and rehabi litation have set the objective of introducing and carrying out more effective measures. However public support should not be overemphazised. Compared with cardiovascular diseases, rheumatic disorders, neurological conditions such as multiple sclerosis etc. the support for research in the psychoses is compa rably scanty and in many countries of the world completely absent. Psychiatry in the true sense of the word has achieved objective progress only since, beginning with the Age of Enlightenment, it has become more closely allied with the natural sciences, and through the influence of some prominent representatives, such as PINEL in France and GRIESINGER in Ger many, become associated with facuIties of medicine. This desirable situation has only been attained in some parts of the world; setbacks are continually experienced and peculiar amalgamations take place between the natural sci ences and shamanism. With the 7th new edition of Karl LEONHARD'S "Classification of Endogenous Psychoses and their Differentiated Etiology" the "World Decade ofthe Brain", proclaimed in 1990 approaches its middle. Results from the so called endogenous psychoses have so far been sparse. It is true that some symptoms of these disorders may be relieved with neuroleptic dmg therapy; cures however have not been achieved. Nothing is known about effective prevention. For the affective disorders the introduction of lithium as a pro phylactic measure is noteworthy, but even this treatment is not entirely reli able and may be associated with undesirable side effects placing an undue burden on the patient. The treatment of endogenous psychoses has almost VI Editor's Comment stood still in the last three decades. It is still necessary to use partly effective and insufficiently reliable chemical substances in our treatment. In spite of all the enticements of modern marketing strategies better medications have not yet been found. It is worth remembering that already in the 19th century (for instance KAI-lLBAUM and several French authors) a number of nosological entities had been described among the endogenous psychoses. In the same century, how ever, researchers such as Heinrich NEUMANN and Wilhelm GRIESINGER had postulated a "unitary psychosis". Emil KRAEPELIN (1856-1925) proposed a partial compromise by separat ing the large field of dementia praecox with unfavorable prognosis from the field of manic-depressive conditions with favorable prognosis. This cre ation of a bimodal concept led to a dichotomy which for research has not proved to be very fruitful up to the present time. In spite of this subdivision KRAEPELIN described masterfully many subcategories, taking into acount cross-sectional and longitudinal symptomatology which even today may be considered to be quite valid, but towards the end of his life he lost the strength to develop this classification further. Eugen BLEULER (1857-1939) took over the concept of dementia praecox/manic-depressive illness, but completely ignored the prognostic aspects which KRAEPELIN (apart from a few exceptions) had held to be of greatest value. Thus he combined a large proportion of psychoses, which KRAEPELI had included under the manic depressive illnesses, with the conditions which he now called "schizophre nias" or "schizophrenia". He himself was convinced that he was dealing with several nosological entities; nevertheless it is a tragic aspect of his creative research that all his life he was looking for so-called "basic disturbances" of "schizophrenia", which of course he did not find, because they do not exist. BLEULER did not bluntly reject FREun's psychoanalysis; his positive attitude helped by Adolf MAYER resulted in his being made to feel welcome in Anglo American psychiatry. Furthermore his cross-sectional symptomatological description, leaving aside prognosis, was accepted there more easily, for example by MAYER-GROSS. During the last several decades at certain intervals of time and with good intention classification systems have been worked out by psychologists and psychiatrists by means ofvoting and consensus; descriptions of these systems come into the hands ofmental health professionals in great regularity in the form of authoritative guidelines. All too easily it is being overlooked that behind it all no progress is made in research, merely restructurization. The latter has not been derived from lifelong observations of patients. Therefore from the scientific point ofview this remains at least questionable. Interrater reliability keeps on being stressed at the expense of clinical validity. It even happened that clinical investigations requiring a high degree of knowledge and experience possessed by only the most skilful were delegated to "trained" students, psychologists, and scientific assistants in their first years of apprenticeship. Of course such mathematically attractive results cannot provide satisfaction. Witness the fruitlessness ofour decades long research. }.'ditors Comment VTI

Contemporaneously with KRAEPELIN'S efforts Carl WERNICKE (1848-1905) in Berlin, Breslau and later Halle worked in the field of central neurology (particularly ofaphasia) as well as in the field ofdescriptive psychiatry, From his findings in psychopathology he repeatedly postulated a "theory of dis junction" ("Sejunktionstheorie"), that is, an interruption of the connections between neural systems, leading either to a loss of functions, an excess of function or a faulty function. This disjunction may, for example in the area of psychomotility, lead to akinesia, hyperkinesia, or parakinesia. He sug gested that a similar process occurred in thinking and in disturbances of the will. In so doing he found a powerful opponent in Karl JASPERS, who labelled him as a "brain mythologist". JASPERS had evidently overlooked the essential element in Wernicke's research, that is the careful elaboration of psy chopathological conditions in cross-section as well as in their longitudinal course; even today in their precision WERNICKE'S descriptions are of great value. Among other surviving concepts WERNICKE coined the terms "akine sia", "hyperkinesia", "anxiety psychosis". His pupil Karl KLEIST (1879-1960) followed WERNICKE in neurology as well as in psychiatry and psychopathology; by means of extensive studies of patients with brain trauma, KLEIST thoroughly confirmed and expanded WERNICKE'S observations (TEICHMANN 1990). Differences between WERNICKE and KRAEPELIN became more apparent leading to a certain antagonism between them. This was continued with KLEIST, who never accepted such a gross division into two as KRAEPELIN and his pupils had proposed. As well he doubted the untiy of manic-depressive illness and asked his pupil Edda NEELE to investigate monopolar/bipolar depressions (1949). Furthermore he separated the cycloid psychoses from the field of manic-depressive illness and from a part of the schizophrenias. From his observations are derived masterful psychopathological descriptions which can hardly be further improved. Unfortunately he lacked the time to summarize all his psychopathological investigations so that now they have to be read in various original papers. Karl LEONHARD was a pupil of KLEIST. In 1936 he came from the Gabersee psychiatric hospital to Frankfurt/Main, and brought with him the concept of "defect schizophrenic clinical pictures". He thus became a recognized lec turer (in German "Habilitation") at Frankfurt University with the full sup port of KLEIST. Here was found for the time a clearseparation ofa large por tion of"schizophrenic" diseases, which at first KLEIST but later also LEONHARD did not include under the group of schizophrenias, but were considered as "system diseases" of the brain. These "systematic" schizophrenias were thought to have originated in a weakness either caused by a constitutional hereditary disposition or by environmental factors. They have a chronic insidious onset and their course is progressive with poor prognosis. In fact investigations for several decades, already introduced at KLEIST'S clinic, revealed that evidently these conditions with a deleterious course but little genetic predisposition showed nosologically a sharply limited characteriza tion. After early admixtures of accessory symptoms such as hallucinations VIII t.aitor's Comment and delusions they become stable some years later, and may be identified again and again whatever therapeutic procedures are used. These hebephre nias, paraphrenias, and catatonias show entirely different clinical pictures which can only be learned and recognized by applying a high degree ofintel lectual effort. Nevertheless the latter is worthwhile, since here we do not have hereditary forms of mental illnesses before us and thus can avoid a source of error in therapy and research. Of course Karl LEONHARD'S etiological considerations which in this book he points out in a highly differentiated manner for each of his diagnostic entities may be held to be somewhat imaginative speculations. For all that, they are based on his conscientious observations and passionately ingenious reflections throughout the decades. Nevertheless he himself accepts that there may be other ways of explaining his findings. Comparisons of his views on early childhood catatonia with those in the literature must be considered to be highly weighted in his favor and may turn out to be very relevant in the education offuture generations. The so-called "unsystematic schizophrenias" (periodic catatonia, affective paraphrenia, cataphasia) are of great scientific significance in so far as in them heredity plays a striking role, thus leading themselves to modern genetic research par excellence. Their course at the beginning is usually stormy, later there are often phases with the development of more or less clear-cut defects. When strong affective elements are present symptoms may be well controlled by means of modern neuroleptic therapy and thus offer a good therapeutic field for modern pharmacotherapy. Nevertheless it must be mentioned critically that true cures are hardly possible. These illnesses show, even with few symptoms, the formation of typical defects (periodic catatonia: apathy; affective paraphrenia: mistrust, suspicion; cataphasia: per plexity, poverty of affect). Even here LEONHARD, beside the striking genetic findings, expressed important thoughts concerning the role of parents and siblings during the development of the patient's childhood; even if these thoughts are not convincing they are at least noteworthy. With regard to the cycloid psychoses (anxiety-happiness psychosis, excited-inhibited confusion psychosis, hyperkinetic-akinetic motility psy chosis) LEONHARD in building on the research of his predecessors WERNICKE and KLEIST sees things rather differently. He deserves the credit of having dif ferentiated these from the other forms of psychoses. He describes precise psychopathological clinical pictures which at times temporarily overlap with other cycloid psychoses, so that they are not always easily recognized in cross section even by experienced observers. Occasionally there are transitions, at least of short duration, with unsystematic schizophrenias or even manic depressive illness. This diagnostic problem may however be solved in most cases if the longitudinal development of the condition is carefully analysed. What is important for therapy is that medications in practice produce only symptomatic improvement and do not have any real influence on the course of the psychosis. Cycloid psychoses also show spontaneous remissions and may not leave any defect behind. Continued medication with neuroleptics Editor's Comment IX

during the healthy periods are more a hindrance than a help and may lead to toxic side effects which may disable the patient in his every day life and brand him as mentally ill. Because of this LEONHARD has made a passionate appeal for the careful differentiation of the cycloid from the other psy choses. The prognosis, which is exceedingly important not only for the patient but also for his family may be of great value, keeping in mind how much the burden of mental illness is carried by the whole family. To be sure, great caution is indicated with regard to predicting the duration of a phase, since there are cycloid psychoses which last from a few days to several years. Nevertheless there is good reason in the last analysis to retain a favorable prognosis. The familiar incidence in contradiction to the unsystematic psy choses is low (about 4%). Here too his etiological reflections in terms offam ily and siblings are interesting, and can only be understood on the basis of LEONHARD'S collective works (Biopsychology of Endogenous Psychoses, 1970; Biological Psychology, 1993). They will be rejected by many. But this does not in the least diminish the value of the exact descriptions and con sideration of hereditary factors offered here. The concept of manic-depressive illness with its usual bipolar course was taken over by KLEIST and by LEONHARD from KRAEPELIN, and required no essential additions. However LEONHARD differentiated it clearly from pure melancholia and pure depression. This had always been surmised by KLEIST, but was confirmed by Edda NEELE (1949), and then proved by LEONHARD and his co-workers from their investigations of families through observing the clinical and genetic characteristics. There is thus no doubt that Karl LEON HARD has conclusively proved that the discovery of the monopolar/bipolar dichotomy of manic-depressive illness in its phenomenology and genetics was valid. ANGST (1966), PERRIS (1966) and WINOKUR (1969) in their investi gations have always confirmed this even without having undertaken a phe nomenological cross-sectional and longitudinal analysis. On the basis of his investigations Karl LEONHARD assumes for manic-depressive illness as differ entiated by him an important hereditary flaw, equivalent to genetic domi nance. No connection with the X-chromosome was found by him in his extensive material despite such proposals by several authors. Even the dis crepancy found in monozygotic twins with regard to the incidence of these illnesses he explains as due to a different affective lability, which does not have to be genetically inherited, but which may eventually promote or pre vent the onset of the illness in one or the other of the twin partners. This he mentions primarily as a hypothesis in order to stimulate discussion. The separation of mania occurring in phases has likewise been recog nized all over the world. These are rather rare diseases to which particular attention ought to be paid; this happens all too infrequently. LEONHARD has quite independently separated five pure depressions: agitated (also trans lated as "harried"), hypochondriacal, self-tortured, suspicious, apathetic, as well as five pure euphorias: unproductive, hypochondriacal, exalted, confab ulatory, indifferent. These clinical pictures occur infrequently, but are being seen again and again by experienced clinicians, sometimes misdiagnosed as x Editor's Comment

atypical depression or as neuroses. But Karl LEONHARD has described them with such sharp circumscription that the diagnoses cannot be missed from observation. It is quite incomprehensible that these characteristic clinical pictures continue to be pushed this way or that way diagnostically. Here he postulated in each case an affliction of a particular emotional layer in which pathological thinking is occasioned by the type of pathological affect. This he underscores in his book "Biological Psychology" where he gains valuable insights from the pure depressions, the pure euphorias, as well as the sys tematic schizophrenias as derived from his observations of the symptoms. These insights ought to help modern scientific psychology emerge from the blind alley of fruitless research. The question has often been asked why the "WERNICKE-KLEIST-LEON HARD-SCHOOL" ofpsychiatry has not prevailed internationally. There are sev eral answers to this question: first the fact that WERNICKE died early and thus was unable to defend his point ofview from that of the influential KRAEPELIN; secondly, critics such as JASPERS (who worked in psychiatry for only a few months), and many others who branded him and his pupil KLEIST as "brain mythologists" and ignored him as well. Against the differentiated nosology of the "WERNICKE-KLEIST-LEON HARD-SCHOOL" numerous other objections have been raised by essentially uninformed critics. Many modern psychiatrists reproached LEONHARD saying that his nosological entities were too subjective, they had been elaborated from clinical observations, and lacked "objective" confirmation. He was also criticized in that he did not develop any "rating scales" by means of which individual clinical pictures could have been identified in "operationalized" form by third parties. To counter these criticisms is the fact that LEONHARD had personally with his co-workers examined several hundreds, even thou sands of patients before each nosological entity was elaborated. His investi gations spanning many decades, were conducted by him personally and were meticulously described by him in writing; in his "Frankfurt series" they con sisted ofseveral hundred cases, in his "Berlin series" of 1465 cases. Of course the figures of the differentiated clinical pictures vary greatly, from the very frequent manic-depressive illness and the cycloid psychoses to the single forms of unsystematic and systematic schizophrenias. Single subforms he observed only occasionally, a fact which he mentions every time. In rare cases (e.g. indifferent euphoria) he presented only a few case histories. Complicated combined systematic forms likewise were seen by him in rela tively few cases, because these were almost always being cared for in psychi atric institutions because of their severity. This has led to criticisms that he had modelled individual categories, as if on a drawing board. From observa tions that my co-workers and I were able to make regarding his explorations of many years I cannot remember a single case in which he was unable to describe a type of illness in all its psychopathological differentiations in the way he had suggested. In this way it became understandable again and again why his method of diagnosing remained closed indefinitely to so many psy chiatrists. The diagnosis of his nosological categories is complete only if all Editor's Comment XI

symptoms found in his descriptions can be diagnosed in the patient. Indi vidual mainly qualitative changes exclude the correct diagnosis. Therefore in his descriptions one is not dealing with only clinical impressions, artful cir cumscriptions, reminiscences or suppositions, but with psychopathological descriptions made and modified in their empirical exactitude for decades, representing the most important elements in a most striking manner. Thus the most careful operationalizations were practised, in which firm associa tions of symptoms were described. It is unthinkable that symptoms the way he sees them can be removed from the groupings to form other clinical enti ties. Each disturbance of thinking, for instance in systematic paraphrenia, has its own characteristic form, and can be found only with this condition. The same applies to auditory hallucinations which may occur in practically all psychiatric conditions, but which for LEONHARD acquired their nosologi cal significance only in their definite firm legitimate symptomatic connec tion, that is, a syndrome. Deviation from this firm conformity or inattentive ness will always lead to the wrong diagnosis. Numerous scientists have tried to "operationalize" LEONHARD and have always failed, because by doing so less exact or less appropriate pictures arose. Of course this increases the dif ficulty of accepting and transmitting his point of view. In comparison with neurology in which one is essentially dealing with motor and sensory phe nomena whose differential diagnosis presents enormous problems, why should these be any less when dealing with the highest human functions? In neurology additional somatic findings (imaging and laboratory techniques) considerably facilitate diagnosis. Here in psychiatry it is to be hoped that soon with the help of modern scientific procedures additional diagnostic techniques may bring more certainty to this field. In the meantime we have to fall back on the painstaking road of psychopathological differentiation in order to obtain the most homogeneous groups for investigation. Early results in clinical genetics have already been shown to be impressive by means of such a nosological differentiation (FRANZEK and BECKMANN 1991). Differential methods of therapy as well have found a more sensible application than if they had been used in an undifferentiated manner for a supposedly unitary psychotic continuum (BECKMANN et al. 1992). With regard to prognosis LEONHARD'S classification of endogenous psy choses brings enormous advantages, thereby avoiding many misjudgements which have contributed to giving our profession such bad publicity. Further more it protects us from deceptive illusions, encourages us in our therapeu tic endeavours, and keeps in check exaggerations which occur here and there. In research concerning the etiology of endogenous psychoses the type of differentiated psychopathology according to LEONHARD is indispensable. Here too some early encouraging results have been obtained, which have been described partially by LEONHARD himself (UNGVARI 1993). The possibilities of danger because of early childhood isolation in single child families or distinct position in the order of siblings are shown impres sively. Other investigators found distinct environmental influences in the XII Editor's Comment

prenatal period in differential nosological subdivision (STOBER et al. 1993a, 1994). Imaging techniques have revealed quite significant findings in certain nosological subdivisions (BECKER et al. 1993) . Research in electroen cephalography has revealed similar findings (STRIK et al. 1993, WARKENTIN et al. 1992). The undersigned came to know the validity of LEONHARD'S concepts through his work for several years with Karl LEONHARD himself. Eventually he and his co-workers Ernst FRANZEK and Gerald STOBER undertook lengthy studies to test the validity of LEONHARD'S concepts; by means of a series of investigations independent from one another they achieved high coeffi cients of reliability (Cohen's kappa 0.90). Since a number ofother experienced clinicians have been able to validate the classification system of the WERNICKE-KLEIST-LEONHARD-SCHOOL, there now exists the wellfounded prospect that this unfortunately rather difficult but singularly relevant concept may succeed in the future despite of the pre vailing international classifications (ICD and DSM). In favor of this concept should be mentioned the confirmation by ANGST, PERRIS and WINOKUR ofthe monopolar/bipolar dichotomy, the confirmation of the concept of the cycloid psychoses (PERRIS 1974, BROCKINGTON et al. 1982, BECKMANN et al. 1990) and of periodic catatonia, an unsystematic form of schizophrenia described by GJESSING (1974); furthermore the supporting contribution by ASTRUP (1979) on the systematic schizophrenias. Individual clinical descrip tions have been published by STOBER et al. (1993b) (self-tortured depres sion) or STOBER et al. (1993c) (proskinetic catatonia). The preponderance of Anglo-American psychiatry after World War II, based on KRAEPELlN, Kurt SCHNEIDER and BLEULER, offered in a greatly sim plified form a two-diagnoses-system and was therefore accepted much more gratefully than the highly differentiated nosological system of Karl LEON HARD. The continued changes proposed in each revision of ICD or DSM seem to promote the feeling that progress is being made, although the direc tion is further and further away from the cross-sectional/longitudinal diag nostic system of the most experienced clinicians. One may suspect that this path may lead to many decades of fruitless research, and will not serve well the "World Decade of the Brain". Even today critical voices have been heard with regard to the present day diagnostic scheme (VAN PRAAG 1993, BROCK INGTON 1992, FRANZEK and BECKMANN 1991). During LEONHARD'S lifetime there was no lack of international attention. His principal work has been translated into several languages and published repeatedly. His other books as well have been published in several editions, which due to the fact that they were published in the German Democratic Republic had very limited numbers and now are no longer available in sec ond-hand book stores. The scientific climate has resulted in a considerable number of publications ofwhich several are listed at the end of this chapter. The findings from research with twins which had been omitted from the last edition of the book have now been included because of their importance; in the international literature they had been totally neglected, but are relevant EditM's Comment XIII as a point ofdeparture for LEONHARD'S reflections on differentiated etiology. Besides even without these findings they emphasize the hereditary factors in the various nosological entities. In conclusion cordial thanks are due to Ernst FRANZEK and Gerald STOBER for their collaboration and review of the manuscript. They deserve great credit for continuing the scientific work of Karl LEONHARD. Bruno PFUHL MANN and SABINE VOSS gave very valuable assistance in the correction and typing of the manuscript.

Wurzburg, April 1995 Helmut Beckmann References

AngstJ (1966) Zur Atiologie und Nosologie endogener Psychosen. Monogr. Gesamtgeb. Neurol. Psychiat., H. 112. Springer, Berlin Astrup C (1979) The chronic schizophrenias. Universitetsforlaget, Oslo Becker T, Stober G, Lanczik M, Hofmann E, Franzek E (1994) Cranial computed tomog raphy and differentiated psychopathology - are there patterns of abnormal CT find ings? In: Beckmann H, Neumarker KJ (Eds) Endogenous psychoses. Leonhard's impact on modern psychiatry. Ullstein Mosby, Berlin Beckmann H, Fritze J, Franzek E (1992) The influence of neuroleptics in specific syn dromes and symptoms in schizophrenics with unfavorable long-term course. Neuro psychobiol 26: 50-58 Beckmann H, FritzeJ, Lanczik M (1990) Prognostic validity of the cycloid psychoses. Psy chopathoI23:205-212 Bleuler E (1911) Dementia praecox oder die Gruppe der Schizophrenien. In: Aschaffen burg, G (Ed) Handbuch der Psychiatrie. Deuticke, Leipzig Wien Brockington IF, Perris C, Kendell RE, Hillier YE, Wainwright S (1982) The course and outcome of cycloid psychoses. Psychol Med 12: 97-105 Brockington IF: Schizophrenia: yesterday's concept. Eur Psychiat 7: 203-207 Franzek E, Beckmann H (1991) Syndrom- und Symptomentwicklung schizophrener Langzeitverlaufe. Nervenarzt 62: 549-556 Gjessing LR (1974) A review of periodic catatonia. Bioi Psychiat 8: 23-45 Kleist K (1947) Fortschritte der Psychiatrie. Kramer, Frankfurt Kraepelin E (1923) Psychiatrie. Ein Lehrbuch fUr Studierende und Arzte, 8. Aufl. Barth, Leipzig Neele E (1949) Die phasischen Psychosen nach ihrem Erscheinungs- und Erbbild. Barth, Leipzig Perris C (1974) A study of cycloid psychoses. Acta Psychiat Scand 50: 7-75 (Suppl. 253) Perris C (1966) A study of bipolar (manic-depressive) and unipolar recurrent depressive psychoses. Acta Psychiat Scand 42 (Suppl. 194) van Praag H (1993) "Make-Believes" in psychiatry or the perils of progress. Brunner/ Mazel, New York Stober G, Franzek E, Beckmann H (1993a) Obstetric complications in distinct schizo phrenic subgroups. Eur Psychiat 8: 293-299 Stober G, Franzek, E, Beckmann H (1993b) Die selbstqualerische Depression. Eine Form monopolarer endogener Depressionen. Nervenheilkunde 12: 166-169 Stober G, Franzek E, Beckmann H (1993c) Die "Proskinetische Katatonie". Ein kasuis tischer Beitrag zur Psychopathologie chronisch schizophrener Psychosen. Kranken hauspsychiatrie 4: 70-73 XIV Editor':~ Comment

Stober G, Franzek E, Beckmann H (1994) Schwangerschaftsinfektionen bei Ml"lttern von chronisch Schizophrenen. Nervenal-zt 65: 175-182 Strik WK., Dicl-ks T, Franzek E, Maurer K, Beckmann H (1993) Differenccs in P300 ampli tudes and topography between cycloid psychoses and schizophrenia in Leonhard's classification. Acta Psychiat Scancl 87: 179-183 Teichmann G (1990) The influence of Karl Kleist on the nosology ofKarl Leonhard. Psy chopathol 13: 267-276 Ungvari GS (1993) The Wernicke-Kleist-Leonhard school of psychiatry. Bioi Psychiat 34: 749-752 Warkentin S, Nilsson A, Karlson S, Risberg G, Franze'n L, Gustafson L, Wernicke C (1992) Cycloid psychosis: regional blood flow correlates ofa psychotic episode. Acta Psychiat Scand 85: 23-29 Wernicke C (1900) Grundril3 der Psychiatrie in klinischen Vorlesungen. Thieme, Leipzig Winokur G, Clayton PJD (1969) Family history studies. l. Two types of affective disorders separated according to genetic and clinical factors. In: WortisJ (Ed) Recent advances in biological psychiatry. Plenum, New York (pp. 35-50) Preface to the 6th Edition

No new edition of the "Classification ofEndogenous Psychoses" required on my part so many modifications as this 6th edition. Extensive investigations carried out in recent years resulted in unexpected new knowledge regarding the etiology of endogenous psychoses, leading me to change the title of this book to "Classification of Endogenous Psychoses and their Differentiated Etiology". The new findings might have necessitated a much longer text, but this was avoided by shortening the clinical section. Previously I had pre sented a large number of case histories in order to make the descriptions more meaningful and concrete. In this edition many of these have been omitted. Interested readers may find them in earlier editions. Thus space has been provided for describing in detail etiological observations beside the clinical descriptions. Having previously recognized independent diseases in the various syndromes which are described under endogenous psychoses, my concepts have been given a much sounder base by demonstrating distinct etiologies. Some forms depend primarily on heredity, others on different kinds of psychosocial factors. The influence of siblings on one another, as wen as absence of siblings, has become of special significance. A total1y dis tinct etiology is found in early childhood schizophrenia; this disorder has not been described in earlier editions, as I learned it only in recent years.

Karl Leonhard Translator's Notes

Karl Leonhard's division of schizophrenia into 3 major groups which he called systematic schizophrenias, unsystematic schizophrenias, and cycloid psychoses has found relatively little acceptance in international psychiatry, in which "operational and atheoretical diagnostic systems" prevail (DSMs and ICDs)l. There are probably several reasons why Leonhard's concepts have been all but ignored in the by now huge literature - Leonhard's relative isolation during the latter part ofhis life in East Germany, his use of complex German diagnostic terminology, and his almost stubborn resistance to compromise with the efforts ofmost other experts in psychiatric diagnostic classifications. But in recent years Helmut Beckmann and his collaborators, Eli Robins, Frank Fish, Thomas Ban, Christian Astrup, Carlos, Perris, Ian Brockington and others, have started to revive interest in Leonhard's viewpoints, as the evidence from neurodevelopmental, brain-imaging, genetic and psychoso cial research has mounted, to show more and more convincingly that "schizo phrenia" (singular) is not one entity but consists of several quite different disorders to be considered as "schizophrenias" (plural) or "schizophrenia spectrum disorders"2. The previous translation into English of the 5th edition of Leonhard's "Classification of Endogenous Psychoses" was published in 1979. Before his death in 1988 Leonhard added two new chapters, one on the significance of psychosocial circumstances, and the other on childhood catatonia, which appeared in the 6th edition in 1986; it was subsequently worked over and re edited by Professor Beckmann, giving the translator the opportunity to pre sent a new translation (and at the same time to correct a considerable num ber of mistakes in the 5th edition). Leonhard took great pains in his examination of the patients whom he observed, often conducting "psychic-experimental tests" (not to be confused with "intelligence tests") in which he asked patients to explain the meaning of proverbs. Some of the latter have English equivalents, others do not.

DSM means Diagnostic and Statistical Manual (of the American Psychiatric Associa tion); ICD means International Classification of Diseases (of the World Health Orga nization) For review see: Beckmann H, Neumarker KJ (eds) (1995) Endogenous psychoses Leonhard's impact on modern psychiatry. Ullstein Mosby, Wiesbaden XVIII Translator's Note

Explanatory footnotes are given in the text. Since patients' responses may include play on certain words contained in the German proverbs but not in the English equivalents, on some occasions the exact translation from the German had to be given. Apart fi'om the translation of Leonhard's differentiated diagnostic terms (which in English might not always reflect accurately what the German terms meant), the translator also preferred to refer to and retain "Nervenklinik"as "Psychiatric Hospital", and "kranke Eltern" or "kranke Geschwister" as "affected parents" or "affected siblings." The Wurzburg School of Psychiatry, led by Helmut Beckmann, has been conducting extensive research on schizophrenia spectrum disorders for the last 15 years, testing many of Leonhard's concepts and finding them valid in many respects. Their work has been published for the most part in European and some American psychiatricjournals, but one important paper on a twin study was published in theJanuary 1998 issue ofthe AmericanJournal ofPsy chiatry3 which should be of particular interest, not only to North American psychiatrists, but also to all those conducting research on the genetics of endogenous psychoses.

Montreal, September 1998 Charles H. Cahn

Franzek E and Beckmann H (1998) "Different genetic background ofschizophrenic spectrum psychoses: a twin study". Am] Psychiatr'y 155: 76-83 Table of Contents

Introduction...... 1 Clinical Pictures of Phasic Psychoses (without Cycloid Psychoses) 6 Manic-Depressive Illness 7 Pure Melancholia and Pure Mania 16 Pure Melancholia 17 Pure Mania 21 Pure Depressions and Pure Euphorias 24 Pure Depressions 24 Agitated Depression 25 Hypochondriacal Depression... 30 Self-Tortured Depression 36 Suspicious Depression 39 Apathetic Depression . 43 Pure Euphorias 48 Unproductive Euphoria 48 Hypochondriacal Euphoria 50 Exalted Euphoria .. 53 Confabulatory Euphoria 56 Indifferent Euphoria 59 The Cycloid Psychosis 61 Anxiety-Happiness Psychosis 62 Excited-Inhibited Confusion Psychosis 69 Hyperkinetic-Akinetic Motility Psychosis 75 The Unsystematic Schizophrenias 82 Mfective Paraphrenia 82 Cataphasia (Schizophasia) 95 Periodic Catatonia...... 104 The Systematic Schizophrenias 113 Simple Systematic Schizophrenias 114 Catatonic forms 115 Parakinetic Catatonia 115 Manneristic Catatonia 123 Proskinetic Catatonia.. 127 Negativistic Catatonia 133 Speech-Prompt Catatonia 139 Sluggish Catatonia 146 xx Table ofContents

Review of the Family Picture ofSystematic Catatonias 154 Hebephrenic Forms 156 Foolish Hebephrenia 157 Eccentric Hebephrenia 160 Shallow Hebephrenia 165 Autistic Hebephrenia 169 Review of the Family Picture of Systematic Hebephrenias 172 Paranoid Forms 173 Hypochondriacal Paraphrenia 174 Phonemic Paraphrenia 179 Incoherent Paraphrenia 185 Fantastic Paraphrenia 191 Confabulatory Paraphrenia... 199 Expansive Paraphrenia 206 Review of the Family Picture of Systematic Paraphrenias 214 Final Remarks on the Simple Systematic Forms ofSchizophrenia 215 Combined Systematic Schizophrenias 216 Combined Systematic Catatonias 216 Combined Systematic Hebephrenias 224 Combined Systematic Paraphrenias 227 Family Picture ofCombined Systematic Schizophrenias 247 Comments 248 Age of Onset, Sex Incidence, Course 250 Statistical Findings from Investigations before 1968 250 Age of Onset, Sex Incidence, and Number of Phases in the Phasic Psychoses (Including the Cycloid) 250 Incidence of Psychoses in the Families of Phasic Psychoses (Including the Cycloids) 259 Summary: Principal Findings in Phasic (Including Cycloid) Psychoses 261 Age ofOnset, Sex Incidence, and Course in the Schizophrenias (Investigations before 1968) 263 Number of Psychoses in the Families ofSchizophrenics 269 Statistical Findings from Investigations after 1968 271 The Question of Endogenous Mixed Psychosis 275 Etiology of Endogenous Psychoses 278 Significance of Hereditary Disposition 279 Significance of Psychosocial Circumstances 283 Lack of Communication in the Development of Systematic Schizophrenias 285 Absence of Systematic Schizophrenias in Monozygotic Twins.. 285 Lack of Communication in Systematic Schizophrenia of Childhood 288 Siblings of Patients with Systematic Schizophrenias 290 Prophylaxis of Systematic Schizophrenias...... 299 Table ofContents XXI

Exogenous and Constitutional Causes of the Unsystematic Schizophrenias 301 Periodic Catatonia 301 Mfective Paraphrenia 308 Cataphasia 310 Exogenous and Constitutional Causes of Cycloid Psychoses 313 Exogenous and Constitutional Causes of Manic-Depressive Illness 321 Exogenous and Constitutional Causes of Pure Phasic Psychoses . 324

Early Childhood Catatonia 330 Delineation of Early Childhood Catatonia... 330 The Question of Organicity Underlying the Clinical Picture 331 Diagnosis ofChildhood Schizophrenia. 332 Distribution oflndividual Forms of Early Childhood Catatonia .. 337 Distinguishing Early Childhood Catatonia from Mental Retardation 338 Clinical Pictures of Early Childhood Catatonia 340 Simple Systematic Catatonia of Early Childhood 341 Combined Systematic Catatonia of Early Childhood 355 Etiology of Early Childhood Schizophrenia. 366 Psychosocial Causes 367 Role of Heredity 377 Prophylaxis of Early Childhood Catatonia .. 382 Therapeutic Feasibility in Early Childhood Catatonia 383 Karl Leonhard's Life (1904-1988) 387 References 389 Appendix 393 Subject Index...... 395