Clinicogenetic studies within the scope of Leonhard taxonomy

Using conventional genealogical methods and genetic correlation analysis, the author investigates Leonhard's classification of schizophrenias and cycloid psychoses. According to the second of these methods, the systematic schizophrenias and cycloid psychoses definitely diverge on account of the phenotypic correlations, whereas the unsystematic group presumably occupies a median genetic position between the two categories first mentioned.     

Does symptomatic schizophrenia exist?

The question if there are "symptomatic schizophrenias" has been discussed since the 20s. Schizophrenic psychoses caused be definable and well known brain diseases are presented. All schizophrenic symptoms and syndromes, the first rank symptoms (K. Schneider) too, occur in somatically founded psychoses. The group of paroxysmal transition syndromes in the sense of aura prolongata (continua) and the episodic schizophrenic psychoses in psychomotor epilepsy may be a model for the schizophrenia research. Vital threatening, so-called pernicious catatonic schizophrenias are found on the basis of infectious brain diseases, sometimes only diagnosed in autopsy. Beside acute and reversible symptomatic schizophrenic psychoses there are, even if rarely, recurrent and chronic courses of symptomatic schizophrenias. That certain conditions for the developing of symptomatic schizophrenias are rarely realised, could be an explanation for their rarity. Some findings indicate that the limbic system is significant for symptomatic (and idiopathic) schizophrenic psychoses and the pre- and postpsychotic basic stages determined by dynamic and cognitive basic symptoms, which are phenomenologically very similar to aura symptoms released by stereoelectroencephalographic depth recordings (Wieser). The characteristic features of marked fluctuation, discontinuity and insteadiness of the cognitive thought, perception, psychomotor and cenesthetic phenomena do not speak against an organic brain disorder provided that the traditional process hypothesis is abandoned in favor of a neurobiochemic disorder, fluctuating on its part depending on endogenous as well as psychic-reactive factors.     

Genetic marker findings in systematic and unsystematic schizophrenias

The systematic schizophrenias are marked genetically by a significant surplus of the Gc serum type 1-1 (p less than 0.0005), what can be demonstrated by the separated analysis of the hebephrenias (p less than 0.0005), paraphrenias (p less than 0.01) and catatonias (p less than 0.05) also. Furtheron there is some evidence that the Gc subtype 1F plays a predominant role within the Gc 1-1 excess (p less than 0.01). The unsystematic schizophrenias (periodic catatonias and affective paraphrenias) do not deviate in their Gc distribution from the corresponding control values, but they exhibit contrary to the systematic forms a surplus of the haptoglobin serum group 2-2 like phasic psychoses. The marker findings are discussed with respect to the relevant data of biological psychiatry and biochemical genetics.     

Serum creatinphosphokinase (CPK) in endogenic psychoses]

Creatinphosphokinase (CPK) was determined in 141 patients with manic-depressive and schizophrenic psychoses. In general endogenic psychoses of the manic and depressive type as well as chronic schizophrenias show normal CPK values. In acute cases of paranoid-halluzinatory schizophrenias normal values are predominant. In catatonic schizophrenias, as a rule, clearly increased enzyme activities are found. Thise increased values suggest a postulated somatic disease as a cause of the psychosis. Thus, the determination of CPK provides a useful aid in the diagnosis and control of the course of catatonic schizophrenic.     

Pattern of familial psychoses--systematic and unsystematic schizophrenia and cycloid psychoses]

604 cases were examined, 309 of which were systematic schizophrenics, 191 were unsystematic schizophrenics and 104 cycloid psychotics. With the systematic schizophrenics the average period spent in hospital amounted to 16.9 years, with the unsystematic schizophrenics 13.8 years, with the cycloid psychotics 8.2 years. The systematic schizophrenics were discharged from hospital on average 1.5 times, the unsystematic 2.3 times, the cycloid psychotics 4.1 times. Of the systematic schizophrenics, 37.5% were never discharged after their first admittance to hospital, of the unsystematic 25.7%, of the cycloid psychotics 9.6%. Bipolar fluctuations were detected in 1.6% of the systematic schizophrenics, 49.7% of the unsystematic and 78.8% of the cycloid psychotics. 15.9% of the systematic schizophrenics had occurrences of psychoses in their family compared to 50.8% of the unsystematic and 22.1% of the cycloid psychotics. The systematic schizophrenics had 17.5% of their family ill, the unsystematic 69.6%, the cycloid psychotics 25.0%. Of the parents of the systematic schizophrenics 2.3% were ill, of the parents of the unsystematic schizophrenics 11.6%, of the parents of the cycloid psychotics 5.0%. Of the brothers and sisters of the systematic schizophrenics 2.4% were ill, of the unsystematic schizophrenics 10.9%, of the cycloid psychotics 3.0%. These variations in the pattern and occurrence of psychoses in the family seem to prove that the three groups of endogenous psychoses are genetically separable. There are also differentiating features inside the groups. Periodic catatonia in particular is characterized by the great number of psychotics in the family.     

Psychoses in epilepsy

The heterogenous psychoses in epilepsies, caused by well known conditions, are not rare but associated with regularly a few of seizure-types not with the nature and development of attacks. Polar transitional ranks and converging courses of schizophrenic (accentuated) syndromes in epilepsies and idiopathic schizophrenias are rather frequent. Also (sub-)acute schizophrenic psychoses are corresponding to the complete palette of first and second rank symptoms (K. Schneider) of idiopathic schizophrenias. After manifestations of epilepsy these syndromes can appear at any time. It is given a profile of risks. Progressive avoidance of a. phenylaceturea, b. mixtures of antiepileptics did not put an end to psychotic syndromes: Long-term therapies with 1. Polytherapy, 2. Primidone and Phenytoin (dosedependant) as well as 3. Ethosuximide (-monotherapy) cause a disorder of feed back mechanisms, especially a disturbed regulation of vigilance and sleeping-waking-cycle and their psychological correlates. Carbamazepine and Sodium Valproate are, plasma-level-controlled of preventive antipsychotic effect. Selected neuroleptics of rather slight epileptogenic potency are of going down importance. Benzodiazepines are required mostly in prepsychotic syndromes, Lithium compounds in selected cases. There is no more alternative seizures or psychosis.     

Differential diagnosis of endogenous psychoses in relation to a symptom catalog

The paper introduces a catalog of symptoms to promote in the field of endogenous psychoses differentiated diagnosis, at the same time constituting a prognosis. Symptoms should be more minutely differentiated than is customary in psychiatric questionnaires. Manic-depressive disorders and purely phasal psychoses are distinguished solely in the clinical evaluation. Thus benign cycloid psychoses can be distinguished from malignant unsystematic schizophrenia.     

Studies of higher nervous activity in functional psychoses

Psychiatric illnesses can be conceived of as experiments of nature, providing a variety of pathopsychological mechanisms which may elucidate normal psychological processes. Clinically the reactive psychoses are predominantly psychogenic reaction types. They present disturbances of higher nervous activity, similar to those of the neuroses. The unconditional reflex activity is practically as in normal controls, and the most outstanding finding was the large effect of psychodynamic complex structures. This is a physiological parallel to the clinical manifestations with great concern over experienced mental trauma. In the manic-depressive psychoses the most characteristic feature is a marked disturbance of unconditional reflex activity. This factor may be an important physiological mechanism underlying the more biological than psychodynamic reaction type and partly explain the changes of mood and associated interferences with sleep, body weight, sexual activity, aggression and other instinctual and vegetative functions. Schizophrenic psychoses also present changes of unconditional reflex activity, predominantly in the direction of inhibition of response. In addition there are severe dissociations within and between the three levels of unconditional reflexes and the two signaling systems. It is suggested that schizophrenia represents a functional maladaptation, which can be explained from the principles of autokinesis and schizokinesis established by Gantt in animal experiments. Prognostic models based on experimentally established impairment of performances were shown to predict long-term risks of schizophrenic defects just as well as models based on constellations of clinical symptoms. I would predict that psychophysiology and experimental psychology will become increasingly more important for establishing diagnosis and prognosis in the functional psychoses. The data of this article point toward a basis for a prophylactic psychiatry.     

Provoking endogenous psychoses

For six forms of endogenous psychosis, causal agencies were sought to establish endogenous, physical, and mental provocation. Endocrine causes were found most frequently, 17.5%, in mixed bipolar disorders, followed by cycloid psychoses, 8.5%, which in this respect appear to be closer to the mixed bipolar psychoses, than the unipolar forms at 4.4%. Among the physical causes, the difference in affective psychoses is not particularly great. Cycloid psychoses head the list at 9%. Among the mental causes, pure phase psychoses account for the greatest number, 12.7%, by a wide margin. The three unsystematic forms of schizophrenia revealed a slender link with their causes. Clear distinctions among the causes of the six forms were thus demonstrated.     

Clinical psychopathological characteristics of acute atypical circular affective psychoses

The clinical reality of acute atypical affective psychoses is recognized by almost all psychiatrists. A total of 229 cases of atypical circular psychosis have been studied. In many of these cases the "psychodynamic mobility" of the personality, i.e., the "fixed attitude" according to Usnadse, was studied in addition to a clinical analysis. The method used for this is described, and a number of criteria for evaluation are reported. Also, the thematic apperception test and Rorschach test as well as electroencephalographic examinations have been carried out on many of the patients included in this study. The results of clinical-psychopathological and experimental-psychological examinations enable better diagnoses of acute atypical affective psychoses to be established.     

Functional psychosis in Huntington chorea

The paper considers a case of acute paranoid-hallucinatory psychosis that made its appearance in the fifth year after the manifestation of hereditary chorea. A brief account of the problems involved in psychoses when hereditary chorea is present is given. These psychoses are taken to be functional psychoses as according to Wieck.     

Differential diagnosis and different etiologies of monopolar and bipolar phasic psychoses

Monopolar and bipolar phasic psychoses can be differentiated not only on the course but also on the symptom pattern. This applies also to the euphoric forms which usually are still assigned to Manic-depressive illness. The differential diagnosis is presented. Aetiology is completely different in the monopolar and the bipolar phasic psychoses. Manic-depressive illness has a hereditary basic, whereas in the monopolar ("pure") forms loading is very low. Particularly few psychoses among the relatives have been found in the euphoric forms which demonstrates their independency for if they would belong to Manic-depressive illness they necessarily would show the heavy genetic loading of this bipolar illness. In the pure phasic psychoses external causes were detected when we focused on the sibships in which the probands had grown up. The euphoric patients had relatively many older siblings, the depressive ones relatively few older siblings. A similar difference was found in two cycloid psychoses. Transcultural observations as well as shifts in the incidence rate of the psychoses in our times confirmed our results. Prophylactic measures can be derived.     

Hereditary and psychosocial causes of schizophrenia

On the basis of the examination of patients with endogenic psychosis, indications were obtained that there are forms that mainly develop on a hereditary basis, and forms determined by psychosocial causes. In unsystematic schizophrenia the chief factors are hereditary, above all in periodic catatonia. On the other hand, there are a few indications of a hereditary genesis in systematic schizophrenia although it is just these forms that are distinguished by the severity of their course. By studying twins, cases of schizophrenia in infancy, and the circumstances of brothers and sisters, strong indications of psychosocial causes of systematic schizophrenia were found. Lack of contacts in the course of development appears to the determing factor. In motility psychosis, one of the cycloid psychoses, indications were found that excessive encouragement by other children can be a cause of overstrain and thus may be detrimental. The conclusions drawn are based on concrete findings obtained in a total of 1,114 cases and are for the most part statistically significant.     

Catamnestic studies in patients with anorexia nervosa in puberty

Catamnestic studies ware performed on 15 subjects (13 female und 2 male) who were treated individually with Leonhard's method for puberal emaciation between 1960 and 1970. 14 of the patients, then children, now have a good physical status with normal weight, are coping well with life and are most cases married. One female patient died at age 31 years; when accepted for treatment 15 years ago there was some doubt regarding the diagnosis of a genuine puberal emaciation, and this doubt grew in the subsequent course of events. No connection could be found between her death and emaciation. We can thus consider that the success of individual treatment with Leonhard's method has been confirmed.     

Higher nervous activity in psychiatric patients

A review is presented of studies of higher nervous activity in psychiatric patients. In neuroses and reactive psychoses the basic pathology appears to be centered around the psychogenic complex structures. In addition, neuroses as well as reactive psychoses reveal general disturbances of higher nervous activity. In the schizophrenic and manic depressive psychoses there are indications of disturbances in deep-lying brain structures. Both types of psychoses are heterogeneous groups of clinical conditions. An important task for future experimental studies is to establish the types of disturbances of higher nervous activity in well-defined clinically homogenous groups. The final section deals with prophylactic psychiatry, with special emphasis on Gantt’s suggestions for an international project.     

Indications for the Use of Atypical Antipsychotics in the Elderly

There has been an expanding role for the new generation atypical antipsychotic agents (clozapine, risperidone, olanzapine, and quetiapine) in elderly patients. Their efficacy in the treatment of psychoses associated with schizophrenia is now well established. But psychoses occur in other conditions. This paper will review the current research examining the use of the atypical agents in the treatment of psychoses in the elderly in three somewhat overlapping conditions: schizophrenia, dementia, and Parkinson's disease, as well as in the amelioration of a variety of movement disorders. In the elderly, any of the atypicals can be used to treat schizophrenia, although clozapine may be a second line agent because of its side effect profile. Risperidone may be the drug of choice for the treatment of psychoses and behavioral disturbances in dementia. Clozapine is a primary choice and quetiapine an alternative for the treatment of psychoses in Parkinson's disease; while clozapine and possibly risperidone may be preferred for the initial treatment of some movement disorders. The differential effectiveness of these agents across treatment indications may, in part, be related to their differing affinities at several neurotransmitter receptors. Examination of these relationships in large scale longitudinal studies may help in the development of effective tailored treatments for the elderly.     

On "Setting events" and related concepts

The term "setting event" is examined in light of recent interest in the possible utility of the concept. The term was found to characteristically include properties of environmental variables, functional relations already defined, and other functional relations either unspecified or not identified with any generally-accepted term. "Setting event" as a technical term may be too general and functionally unclear and should thus be viewed with caution. An alternative approach is examined in the recently-proposed term, "establishing operation," which is viewed as a more limited, functionally specific, and therefore preferable approach to the adoption of new technical terms.     

Hemispheric dominance in schizophrenics as determined on extrapyramidal side effects of neuroleptics

Phenomena observed during treatment with neuroleptics were clinically measured in an attempt to determine the difference in vulnerability of the two hemispheres and the relation between this difference and schizophrenic diseases. In the group of systematic schizophrenias the increase in tonus was significantly higher in the dominant hemisphere. This finding is considered a verification of the nosological hypothesis of schizophrenias.     

Simulating consciousness in a bilateral neural network: "nuclear" and "fringe" awareness

A technique for the bilateral activation of neural nets that leads to a functional asymmetry of two simulated "cerebral hemispheres" is described. The simulation is designed to perform object recognition, while exhibiting characteristics typical of human consciousness-specifically, the unitary nature of conscious attention, together with a dual awareness corresponding to the "nucleus" and "fringe" described by William James (1890). Sensory neural nets self-organize on the basis of five sensory features. The system is then taught arbitrary symbolic labels for a small number of similar stimuli. Finally, the trained network is exposed to nonverbal stimuli for object recognition, leading to Gaussian activation of the "sensory" maps-with a peak at the location most closely related to the features of the external stimulus. "Verbal" maps are activated most strongly at the labeled location that lies closest to the peak on homologous sensory maps. On the verbal maps activation is characterized by both excitatory and inhibitory Gaussians (a Mexican hat), the parameters of which are determined by the relative locations of the verbal labels. Mutual homotopic inhibition across the "corpus callosum" then produces functional cerebral asymmetries, i.e., complementary activation of homologous "association" and "frontal" maps within a common focus of attention-a nucleus in the left hemisphere and a fringe in the right hemisphere. An object is recognized as corresponding to a known label when the total activation of both hemispheres (nucleus plus fringe) is strongest for that label. The functional dualities of the cerebral hemispheres are discussed in light of the nucleus/fringe asymmetry.     

Intrahemispheric sex differences in the functional representation of language and praxic functions in normal individuals

Kimura (1980, The Behavioral and Brain Sciences, 3, 240-241; 1983, Canadian Journal of Psychology, 37, 19-35; 1987, Canadian Psychology, 28, 133-147) recently proposed that there are intrahemispheric sex differences in the organization of particular language and praxic functions such that in females these functions are more focally represented. This hypothesis, as well as supporting data, was derived from research with brain-injured subjects. The purpose of the present study was to test the utility of using dual-task methodology for investigating sex-related variation in intrahemispheric functional organization in normal individuals. Women were found to show greater interference than men on concurrent tasks of language and right-hand finger tapping. In support of Kimura's model, the present findings yielded evidence suggestive of intrahemispheric sex differences in the "functional distance" between language and praxic functions within the left hemisphere of normal individuals.