Karl Leonhard

Classification of Endogenous Psychoses

and their Differentiated Etiology

Second, revised and enlarged edition

Edited by Helmut Beckmann

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

Originally published as A ufteilung der endogenen Psychosen und ihre diJJerenzierte Atiologie, 7. neubearbeitete und ergiinzte Auflage

© 1995 Thieme, Stuttgart

The first English edition was published by Irvington Publishers, Ine., © 1979

This work is subject to copyright. AlI rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting,

reproduction by photocopying machines or similar means, and storage in data banks.

© 1999 Springer-Verlag Wien Originally published by Springer-Verlag Wien New York in 1999

Softcover reprint of tbe hardcover 2nd edition 1999

Typesetting: Bernhard Computertext KG, A-I030 Wien

Graphic design: Ecke Bonk

Printed on acid-free and chlorine-free bleached paper SPIN: 10711564

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 Endoge­nous Psychoses". Since then in spite of all innovations and technologicalachievements in the past decades this pronouncement has not lost anythingof its significance and its application to the present day research situation.

Mental and emotional disorders belong to the large group of "diseases ofthe people". From the public health point of view they are of extraordinaryimport for every community. Accordingly, some countries have generouslysupported research efforts in the neurosciences as well as in the physicalsciences with the aim of achieving tangible progress in prevention and pre­cise diagnosis, as well as rehabilitation. Such efforts have amongst others ledto the declaration of the "Decade of the Brain" in the United States andmore recently to that of the "World Decade of the Brain" in which all inter­national societies concerned with the problem of mental health and rehabi­litation have set the objective of introducing and carrying out more effectivemeasures.

However public support should not be overemphazised. Compared withcardiovascular diseases, rheumatic disorders, neurological conditions suchas multiple sclerosis etc. the support for research in the psychoses is compa­rably scanty and in many countries of the world completely absent.

Psychiatry in the true sense of the word has achieved objective progressonly since, beginning with the Age of Enlightenment, it has become moreclosely allied with the natural sciences, and through the influence of someprominent representatives, such as PINEL in France and GRIESINGER in Ger­many, become associated with facuIties of medicine. This desirable situationhas only been attained in some parts of the world; setbacks are continuallyexperienced and peculiar amalgamations take place between the natural sci­ences and shamanism.

With the 7th new edition of Karl LEONHARD'S "Classification ofEndogenous Psychoses and their Differentiated Etiology" the "World Decadeofthe Brain", proclaimed in 1990 approaches its middle. Results from the so­called endogenous psychoses have so far been sparse. It is true that somesymptoms of these disorders may be relieved with neuroleptic dmg therapy;cures however have not been achieved. Nothing is known about effectiveprevention. For the affective disorders the introduction of lithium as a pro­phylactic measure is noteworthy, but even this treatment is not entirely reli­able and may be associated with undesirable side effects placing an undueburden 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 effectiveand insufficiently reliable chemical substances in our treatment. In spite ofall the enticements of modern marketing strategies better medications havenot yet been found.

It is worth remembering that already in the 19th century (for instanceKAI-lLBAUM and several French authors) a number of nosological entities hadbeen described among the endogenous psychoses. In the same century, how­ever, researchers such as Heinrich NEUMANN and Wilhelm GRIESINGER hadpostulated a "unitary psychosis".

Emil KRAEPELIN (1856-1925) proposed a partial compromise by separat­ing the large field of dementia praecox with unfavorable prognosis fromthe field of manic-depressive conditions with favorable prognosis. This cre­ation of a bimodal concept led to a dichotomy which for research has notproved to be very fruitful up to the present time. In spite of this subdivisionKRAEPELIN described masterfully many subcategories, taking into acountcross-sectional and longitudinal symptomatology which even today may beconsidered to be quite valid, but towards the end of his life he lost thestrength to develop this classification further. Eugen BLEULER (1857-1939)took over the concept of dementia praecox/manic-depressive illness, butcompletely ignored the prognostic aspects which KRAEPELIN (apart from afew exceptions) had held to be of greatest value. Thus he combined a largeproportion of psychoses, which KRAEPELI had included under the manic­depressive illnesses, with the conditions which he now called "schizophre­nias" or "schizophrenia". He himself was convinced that he was dealing withseveral nosological entities; nevertheless it is a tragic aspect of his creativeresearch 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 attitudehelped by Adolf MAYER resulted in his being made to feel welcome in Anglo­American psychiatry. Furthermore his cross-sectional symptomatologicaldescription, leaving aside prognosis, was accepted there more easily, forexample by MAYER-GROSS.

During the last several decades at certain intervals of time and with goodintention classification systems have been worked out by psychologists andpsychiatrists by means of voting and consensus; descriptions of these systemscome into the hands of mental health professionals in great regularity in theform of authoritative guidelines. All too easily it is being overlooked thatbehind it all no progress is made in research, merely restructurization. Thelatter has not been derived from lifelong observations of patients. Thereforefrom the scientific point of view this remains at least questionable. Interraterreliability keeps on being stressed at the expense of clinical validity. It evenhappened that clinical investigations requiring a high degree of knowledgeand experience possessed by only the most skilful were delegated to"trained" students, psychologists, and scientific assistants in their first yearsof apprenticeship. Of course such mathematically attractive results cannotprovide satisfaction. Witness the fruitlessness of our 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 of aphasia) as well as in the field of descriptive psychiatry, Fromhis findings in psychopathology he repeatedly postulated a "theory of dis­junction" ("Sejunktionstheorie"), that is, an interruption of the connectionsbetween neural systems, leading either to a loss of functions, an excess offunction or a faulty function. This disjunction may, for example in the areaof psychomotility, lead to akinesia, hyperkinesia, or parakinesia. He sug­gested that a similar process occurred in thinking and in disturbances of thewill. In so doing he found a powerful opponent in Karl JASPERS, who labelledhim as a "brain mythologist". JASPERS had evidently overlooked the essentialelement in Wernicke's research, that is the careful elaboration of psy­chopathological conditions in cross-section as well as in their longitudinalcourse; even today in their precision WERNICKE'S descriptions are of greatvalue. Among other surviving concepts WERNICKE coined the terms "akine­sia", "hyperkinesia", "anxiety psychosis".

His pupil Karl KLEIST (1879-1960) followed WERNICKE in neurology aswell as in psychiatry and psychopathology; by means of extensive studies ofpatients with brain trauma, KLEIST thoroughly confirmed and expandedWERNICKE'S observations (TEICHMANN 1990).

Differences between WERNICKE and KRAEPELIN became more apparentleading to a certain antagonism between them. This was continued withKLEIST, who never accepted such a gross division into two as KRAEPELIN andhis pupils had proposed. As well he doubted the untiy of manic-depressiveillness and asked his pupil Edda NEELE to investigate monopolar/bipolardepressions (1949). Furthermore he separated the cycloid psychoses fromthe field of manic-depressive illness and from a part of the schizophrenias.From his observations are derived masterful psychopathological descriptionswhich can hardly be further improved. Unfortunately he lacked the time tosummarize all his psychopathological investigations so that now they have tobe read in various original papers.

Karl LEONHARD was a pupil of KLEIST. In 1936 he came from the Gaberseepsychiatric hospital to Frankfurt/Main, and brought with him the concept of"defect schizophrenic clinical pictures". He thus became a recognized lec­turer (in German "Habilitation") at Frankfurt University with the full sup­port of KLEIST. Here was found for the time a clear separation of a large por­tion of "schizophrenic" diseases, which at first KLEIST but later also LEONHARDdid not include under the group of schizophrenias, but were considered as"system diseases" of the brain. These "systematic" schizophrenias werethought to have originated in a weakness either caused by a constitutionalhereditary disposition or by environmental factors. They have a chronicinsidious onset and their course is progressive with poor prognosis. In factinvestigations for several decades, already introduced at KLEIST'S clinic,revealed that evidently these conditions with a deleterious course but littlegenetic predisposition showed nosologically a sharply limited characteriza­tion. 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 identifiedagain and again whatever therapeutic procedures are used. These hebephre­nias, paraphrenias, and catatonias show entirely different clinical pictureswhich can only be learned and recognized by applying a high degree of intel­lectual effort. Nevertheless the latter is worthwhile, since here we do nothave hereditary forms of mental illnesses before us and thus can avoid asource of error in therapy and research.

Of course Karl LEONHARD'S etiological considerations which in this bookhe points out in a highly differentiated manner for each of his diagnosticentities may be held to be somewhat imaginative speculations. For all that,they are based on his conscientious observations and passionately ingeniousreflections throughout the decades. Nevertheless he himself accepts thatthere may be other ways of explaining his findings. Comparisons of his viewson early childhood catatonia with those in the literature must be consideredto be highly weighted in his favor and may turn out to be very relevant in theeducation of future generations.

The so-called "unsystematic schizophrenias" (periodic catatonia, affectiveparaphrenia, cataphasia) are of great scientific significance in so far as inthem heredity plays a striking role, thus leading themselves to moderngenetic research par excellence. Their course at the beginning is usuallystormy, later there are often phases with the development of more or lessclear-cut defects. When strong affective elements are present symptoms maybe well controlled by means of modern neuroleptic therapy and thus offer agood therapeutic field for modern pharmacotherapy. Nevertheless it mustbe mentioned critically that true cures are hardly possible. These illnessesshow, even with few symptoms, the formation of typical defects (periodiccatatonia: apathy; affective paraphrenia: mistrust, suspicion; cataphasia: per­plexity, poverty of affect). Even here LEONHARD, beside the striking geneticfindings, expressed important thoughts concerning the role of parents andsiblings during the development of the patient's childhood; even if thesethoughts are not convincing they are at least noteworthy.

With regard to the cycloid psychoses (anxiety-happiness psychosis,excited-inhibited confusion psychosis, hyperkinetic-akinetic motility psy­chosis) LEONHARD in building on the research of his predecessors WERNICKEand KLEIST sees things rather differently. He deserves the credit of having dif­ferentiated these from the other forms of psychoses. He describes precisepsychopathological clinical pictures which at times temporarily overlap withother cycloid psychoses, so that they are not always easily recognized in cross­section even by experienced observers. Occasionally there are transitions, atleast of short duration, with unsystematic schizophrenias or even manic­depressive illness. This diagnostic problem may however be solved in mostcases if the longitudinal development of the condition is carefully analysed.What is important for therapy is that medications in practice produce onlysymptomatic improvement and do not have any real influence on the courseof the psychosis. Cycloid psychoses also show spontaneous remissions andmay 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 leadto toxic side effects which may disable the patient in his every day life andbrand him as mentally ill. Because of this LEONHARD has made a passionateappeal for the careful differentiation of the cycloid from the other psy­choses. The prognosis, which is exceedingly important not only for thepatient but also for his family may be of great value, keeping in mind howmuch 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 favorableprognosis. The familiar incidence in contradiction to the unsystematic psy­choses is low (about 4%). Here too his etiological reflections in terms of fam­ily and siblings are interesting, and can only be understood on the basis ofLEONHARD'S collective works (Biopsychology of Endogenous Psychoses,1970; Biological Psychology, 1993). They will be rejected by many. But thisdoes not in the least diminish the value of the exact descriptions and con­sideration of hereditary factors offered here.

The concept of manic-depressive illness with its usual bipolar course wastaken over by KLEIST and by LEONHARD from KRAEPELIN, and required noessential additions. However LEONHARD differentiated it clearly from puremelancholia and pure depression. This had always been surmised by KLEIST,but was confirmed by Edda NEELE (1949), and then proved by LEONHARD andhis co-workers from their investigations of families through observing theclinical and genetic characteristics. There is thus no doubt that Karl LEON­HARD has conclusively proved that the discovery of the monopolar/bipolardichotomy of manic-depressive illness in its phenomenology and geneticswas valid. ANGST (1966), PERRIS (1966) and WINOKUR (1969) in their investi­gations have always confirmed this even without having undertaken a phe­nomenological cross-sectional and longitudinal analysis. On the basis of hisinvestigations Karl LEONHARD assumes for manic-depressive illness as differ­entiated by him an important hereditary flaw, equivalent to genetic domi­nance. No connection with the X-chromosome was found by him in hisextensive material despite such proposals by several authors. Even the dis­crepancy found in monozygotic twins with regard to the incidence of theseillnesses he explains as due to a different affective lability, which does nothave to be genetically inherited, but which may eventually promote or pre­vent the onset of the illness in one or the other of the twin partners. This hementions primarily as a hypothesis in order to stimulate discussion.

The separation of mania occurring in phases has likewise been recog­nized all over the world. These are rather rare diseases to which particularattention ought to be paid; this happens all too infrequently. LEONHARD hasquite independently separated five pure depressions: agitated (also trans­lated as "harried"), hypochondriacal, self-tortured, suspicious, apathetic, aswell as five pure euphorias: unproductive, hypochondriacal, exalted, confab­ulatory, indifferent. These clinical pictures occur infrequently, but are beingseen again and again by experienced clinicians, sometimes misdiagnosed as

x Editor's Comment

atypical depression or as neuroses. But Karl LEONHARD has described themwith such sharp circumscription that the diagnoses cannot be missed fromobservation. It is quite incomprehensible that these characteristic clinicalpictures continue to be pushed this way or that way diagnostically. Here hepostulated in each case an affliction of a particular emotional layer in whichpathological thinking is occasioned by the type of pathological affect. Thishe underscores in his book "Biological Psychology" where he gains valuableinsights from the pure depressions, the pure euphorias, as well as the sys­tematic schizophrenias as derived from his observations of the symptoms.These insights ought to help modern scientific psychology emerge from theblind alley of fruitless research.

The question has often been asked why the "WERNICKE-KLEIST-LEON­HARD-SCHOOL" of psychiatry has not prevailed internationally. There are sev­eral answers to this question: first the fact that WERNICKE died early and thuswas unable to defend his poin t of view from that of the influential KRAEPELIN;secondly, critics such as JASPERS (who worked in psychiatry for only a fewmonths), and many others who branded him and his pupil KLEIST as "brainmythologists" and ignored him as well.

Against the differentiated nosology of the "WERNICKE-KLEIST-LEON­HARD-SCHOOL" numerous other objections have been raised by essentiallyuninformed critics. Many modern psychiatrists reproached LEONHARD sayingthat his nosological entities were too subjective, they had been elaboratedfrom clinical observations, and lacked "objective" confirmation. He was alsocriticized in that he did not develop any "rating scales" by means of whichindividual clinical pictures could have been identified in "operationalized"form by third parties. To counter these criticisms is the fact that LEONHARDhad personally with his co-workers examined several hundreds, even thou­sands of patients before each nosological entity was elaborated. His investi­gations spanning many decades, were conducted by him personally and weremeticulously described by him in writing; in his "Frankfurt series" they con­sisted of several hundred cases, in his "Berlin series" of 1465 cases. Of coursethe figures of the differentiated clinical pictures vary greatly, from the veryfrequent manic-depressive illness and the cycloid psychoses to the singleforms of unsystematic and systematic schizophrenias. Single subforms heobserved 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 rela­tively few cases, because these were almost always being cared for in psychi­atric institutions because of their severity. This has led to criticisms that hehad modelled individual categories, as if on a drawing board. From observa­tions that my co-workers and I were able to make regarding his explorationsof many years I cannot remember a single case in which he was unable todescribe a type of illness in all its psychopathological differentiations in theway he had suggested. In this way it became understandable again and againwhy his method of diagnosing remained closed indefinitely to so many psy­chiatrists. 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. Indi­vidual mainly qualitative changes exclude the correct diagnosis. Thereforein his descriptions one is not dealing with only clinical impressions, artful cir­cumscriptions, reminiscences or suppositions, but with psychopathologicaldescriptions made and modified in their empirical exactitude for decades,representing the most important elements in a most striking manner. Thusthe most careful operationalizations were practised, in which firm associa­tions of symptoms were described. It is unthinkable that symptoms the wayhe sees them can be removed from the groupings to form other clinical enti­ties. 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 practicallyall psychiatric conditions, but which for LEONHARD acquired their nosologi­cal significance only in their definite firm legitimate symptomatic connec­tion, that is, a syndrome. Deviation from this firm conformity or inattentive­ness will always lead to the wrong diagnosis. Numerous scientists have triedto "operationalize" LEONHARD and have always failed, because by doing soless exact or less appropriate pictures arose. Of course this increases the dif­ficulty of accepting and transmitting his point of view. In comparison withneurology in which one is essentially dealing with motor and sensory phe­nomena whose differential diagnosis presents enormous problems, whyshould these be any less when dealing with the highest human functions? Inneurology additional somatic findings (imaging and laboratory techniques)considerably facilitate diagnosis. Here in psychiatry it is to be hoped thatsoon with the help of modern scientific procedures additional diagnostictechniques may bring more certainty to this field. In the meantime we haveto fall back on the painstaking road of psychopathological differentiation inorder to obtain the most homogeneous groups for investigation.

Early results in clinical genetics have already been shown to be impressiveby means of such a nosological differentiation (FRANZEK and BECKMANN1991). Differential methods of therapy as well have found a more sensibleapplication than if they had been used in an undifferentiated manner for asupposedly unitary psychotic continuum (BECKMANN et al. 1992).

With regard to prognosis LEONHARD'S classification of endogenous psy­choses brings enormous advantages, thereby avoiding many misjudgementswhich have contributed to giving our profession such bad publicity. Further­more it protects us from deceptive illusions, encourages us in our therapeu­tic endeavours, and keeps in check exaggerations which occur here andthere.

In research concerning the etiology of endogenous psychoses the type ofdifferentiated psychopathology according to LEONHARD is indispensable.Here too some early encouraging results have been obtained, which havebeen described partially by LEONHARD himself (UNGVARI 1993).

The possibilities of danger because of early childhood isolation in singlechild families or distinct position in the order of siblings are shown impres­sively. 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 certainnosological subdivisions (BECKER et al. 1993) . Research in electroen­cephalography has revealed similar findings (STRIK et al. 1993, WARKENTIN etal. 1992).

The undersigned came to know the validity of LEONHARD'S conceptsthrough his work for several years with Karl LEONHARD himself. Eventually heand his co-workers Ernst FRANZEK and Gerald STOBER undertook lengthystudies to test the validity of LEONHARD'S concepts; by means of a series ofinvestigations independent from one another they achieved high coeffi­cients of reliability (Cohen's kappa 0.90).

Since a number ofother experienced clinicians have been able to validatethe classification system of the WERNICKE-KLEIST-LEONHARD-SCHOOL, therenow exists the wellfounded prospect that this unfortunately rather difficultbut singularly relevant concept may succeed in the future despite of the pre­vailing international classifications (ICD and DSM). In favor of this conceptshould be mentioned the confirmation by ANGST, PERRIS and WINOKUR of themonopolar/bipolar dichotomy, the confirmation of the concept of thecycloid psychoses (PERRIS 1974, BROCKINGTON et al. 1982, BECKMANN et al.1990) and of periodic catatonia, an unsystematic form of schizophreniadescribed by GJESSING (1974); furthermore the supporting contribution byASTRUP (1979) on the systematic schizophrenias. Individual clinical descrip­tions have been published by STOBER et al. (1993b) (self-tortured depres­sion) 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 sim­plified form a two-diagnoses-system and was therefore accepted much moregratefully than the highly differentiated nosological system of Karl LEON­HARD. The continued changes proposed in each revision of ICD or DSMseem to promote the feeling that progress is being made, although the direc­tion is further and further away from the cross-sectional/longitudinal diag­nostic system of the most experienced clinicians. One may suspect that thispath may lead to many decades of fruitless research, and will not serve wellthe "World Decade of the Brain". Even today critical voices have been heardwith regard to the present day diagnostic scheme (VAN PRAAG 1993, BROCK­INGTON 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 publishedrepeatedly. His other books as well have been published in several editions,which due to the fact that they were published in the German DemocraticRepublic had very limited numbers and now are no longer available in sec­ond-hand book stores. The scientific climate has resulted in a considerablenumber of publications of which several are listed at the end of this chapter.The findings from research with twins which had been omitted from the lastedition of the book have now been included because of their importance; inthe international literature they had been totally neglected, but are relevant

EditM's Comment XIII

as a point of departure for LEONHARD'S reflections on differentiated etiology.Besides even without these findings they emphasize the hereditary factors inthe 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 greatcredit for continuing the scientific work of Karl LEONHARD. Bruno PFUHL­

MANN and SABINE VOSS gave very valuable assistance in the correction andtyping of the manuscript.

Wurzburg, April 1995

References

Helmut Beckmann

AngstJ (1966) Zur Atiologie und Nosologie endogener Psychosen. Monogr. Gesamtgeb.Neurol. Psychiat., H. 112. Springer, Berlin

Astrup C (1979) The chronic schizophrenias. Universitetsforlaget, OsloBecker T, Stober G, Lanczik M, Hofmann E, Franzek E (1994) Cranial computed tomog­

raphy and differentiated psychopathology - are there patterns of abnormal CT find­ings? In: Beckmann H, Neumarker KJ (Eds) Endogenous psychoses. Leonhard'simpact on modern psychiatry. Ullstein Mosby, Berlin

Beckmann H, Fritze J, Franzek E (1992) The influence of neuroleptics in specific syn­dromes and symptoms in schizophrenics with unfavorable long-term course. Neuro­psychobiol 26: 50-58

Beckmann H, FritzeJ, Lanczik M (1990) Prognostic validity of the cycloid psychoses. Psy­chopathoI23:205-212

Bleuler E (1911) Dementia praecox oder die Gruppe der Schizophrenien. In: Aschaffen­burg, G (Ed) Handbuch der Psychiatrie. Deuticke, Leipzig Wien

Brockington IF, Perris C, Kendell RE, Hillier YE, Wainwright S (1982) The course andoutcome of cycloid psychoses. Psychol Med 12: 97-105

Brockington IF: Schizophrenia: yesterday's concept. Eur Psychiat 7: 203-207Franzek E, Beckmann H (1991) Syndrom- und Symptomentwicklung schizophrener

Langzeitverlaufe. Nervenarzt 62: 549-556Gjessing LR (1974) A review of periodic catatonia. Bioi Psychiat 8: 23-45Kleist K (1947) Fortschritte der Psychiatrie. Kramer, FrankfurtKraepelin E (1923) Psychiatrie. Ein Lehrbuch fUr Studierende und Arzte, 8. Aufl. Barth,

LeipzigNeele E (1949) Die phasischen Psychosen nach ihrem Erscheinungs- und Erbbild. Barth,

LeipzigPerris 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 YorkStober G, Franzek E, Beckmann H (1993a) Obstetric complications in distinct schizo­

phrenic subgroups. Eur Psychiat 8: 293-299Stober G, Franzek, E, Beckmann H (1993b) Die selbstqualerische Depression. Eine Form

monopolarer endogener Depressionen. Nervenheilkunde 12: 166-169Stober G, Franzek E, Beckmann H (1993c) Die "Proskinetische Katatonie". Ein kasuis­

tischer Beitrag zur Psychopathologie chronisch schizophrener Psychosen. Kranken­hauspsychiatrie 4: 70-73

XIV Editor':~ Comment

Stober G, Franzek E, Beckmann H (1994) Schwangerschaftsinfektionen bei Ml"lttern vonchronisch Schizophrenen. Nervenal-zt 65: 175-182

Strik WK., Dicl-ks T, Franzek E, Maurer K, Beckmann H (1993) Differenccs in P300 ampli­tudes and topography between cycloid psychoses and schizophrenia in Leonhard'sclassification. Acta Psychiat Scancl 87: 179-183

Teichmann G (1990) The influence of Karl Kleist on the nosology of Karl Leonhard. Psy­chopathol 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 of a psychotic episode. Acta PsychiatScand 85: 23-29

Wernicke C (1900) Grundril3 der Psychiatrie in klinischen Vorlesungen. Thieme, LeipzigWinokur G, Clayton PJD (1969) Family history studies. l. Two types of affective disorders

separated according to genetic and clinical factors. In: WortisJ (Ed) Recent advancesin biological psychiatry. Plenum, New York (pp. 35-50)

Preface to the 6th Edition

No new edition of the "Classification of Endogenous Psychoses" required onmy part so many modifications as this 6th edition. Extensive investigationscarried out in recent years resulted in unexpected new knowledge regardingthe etiology of endogenous psychoses, leading me to change the title of thisbook to "Classification of Endogenous Psychoses and their DifferentiatedEtiology". The new findings might have necessitated a much longer text, butthis was avoided by shortening the clinical section. Previously I had pre­sented a large number of case histories in order to make the descriptionsmore meaningful and concrete. In this edition many of these have beenomitted. Interested readers may find them in earlier editions. Thus space hasbeen provided for describing in detail etiological observations beside theclinical descriptions. Having previously recognized independent diseases inthe various syndromes which are described under endogenous psychoses,my concepts have been given a much sounder base by demonstrating distinctetiologies. Some forms depend primarily on heredity, others on differentkinds of psychosocial factors. The influence of siblings on one another, aswen as absence of siblings, has become of special significance. A total1y dis­tinct etiology is found in early childhood schizophrenia; this disorder hasnot 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 hecalled systematic schizophrenias, unsystematic schizophrenias, and cycloidpsychoses has found relatively little acceptance in international psychiatry, inwhich "operational and atheoretical diagnostic systems" prevail (DSMs andICDs)l.

There are probably several reasons why Leonhard's concepts have beenall but ignored in the by now huge literature - Leonhard's relative isolationduring the latter part of his life in East Germany, his use of complex Germandiagnostic terminology, and his almost stubborn resistance to compromisewith the efforts of most 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 Brockingtonand others, have started to revive interest in Leonhard's viewpoints, as theevidence from neurodevelopmental, brain-imaging, genetic and psychoso­cial research has mounted, to show more and more convincingly that "schizo­phrenia" (singular) is not one entity but consists of several quite differentdisorders to be considered as "schizophrenias" (plural) or "schizophreniaspectrum disorders"2.

The previous translation into English of the 5th edition of Leonhard's"Classification of Endogenous Psychoses" was published in 1979. Before hisdeath in 1988 Leonhard added two new chapters, one on the significance ofpsychosocial circumstances, and the other on childhood catatonia, whichappeared in the 6th edition in 1986; it was subsequently worked over and re­edited by Professor Beckmann, giving the translator the opportunity to pre­sent a new translation (and at the same time to correct a considerable num­ber of mistakes in the 5th edition).

Leonhard took great pains in his examination of the patients whom heobserved, often conducting "psychic-experimental tests" (not to be confusedwith "intelligence tests") in which he asked patients to explain the meaningof proverbs. Some of the latter have English equivalents, others do not.

DSM means Diagnostic and Statistical Manual (of the American Psychiatric Associa­tion); ICD means International Classification of Diseases (of the World Health Orga­nization)For review see: Beckmann H, Neumarker KJ (eds) (1995) Endogenous psychoses­Leonhard's impact on modern psychiatry. Ullstein Mosby, Wiesbaden

XVIII Translator's Note

Explanatory footnotes are given in the text. Since patients' responses mayinclude play on certain words contained in the German proverbs but not inthe English equivalents, on some occasions the exact translation from theGerman 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 termsmeant), 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 beenconducting extensive research on schizophrenia spectrum disorders for thelast 15 years, testing many of Leonhard's concepts and finding them valid inmany respects. Their work has been published for the most part in Europeanand some American psychiatric journals, but one important paper on a twinstudy was published in theJanuary 1998 issue of the AmericanJournal ofPsy­chiatry3 which should be of particular interest, not only to North Americanpsychiatrists, but also to all those conducting research on the genetics ofendogenous psychoses.

Montreal, September 1998 Charles H. Cahn

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

Table of Contents

Introduction................................................................................................. 1

Clinical Pictures of Phasic Psychoses (without Cycloid Psychoses) 6Manic-Depressive Illness 7Pure Melancholia and Pure Mania 16

Pure Melancholia 17Pure Mania 21

Pure Depressions and Pure Euphorias 24Pure Depressions 24

Agitated Depression 25Hypochondriacal Depression... 30Self-Tortured Depression 36Suspicious Depression 39Apathetic Depression . 43

Pure Euphorias 48Unproductive Euphoria 48Hypochondriacal Euphoria 50Exalted Euphoria .. 53Confabulatory Euphoria 56Indifferent Euphoria 59

The Cycloid Psychosis 61Anxiety-Happiness Psychosis 62Excited-Inhibited Confusion Psychosis 69Hyperkinetic-Akinetic Motility Psychosis 75

The Unsystematic Schizophrenias 82Mfective Paraphrenia 82Cataphasia (Schizophasia) 95Periodic Catatonia........... 104

The Systematic Schizophrenias 113Simple Systematic Schizophrenias 114

Catatonic forms 115Parakinetic Catatonia 115Manneristic Catatonia 123Proskinetic Catatonia.. 127Negativistic Catatonia 133Speech-Prompt Catatonia 139Sluggish Catatonia 146

xx Table of Contents

Review of the Family Picture of Systematic Catatonias 154Hebephrenic Forms 156

Foolish Hebephrenia 157Eccentric Hebephrenia 160Shallow Hebephrenia 165Autistic Hebephrenia 169

Review of the Family Picture of Systematic Hebephrenias 172Paranoid Forms 173

Hypochondriacal Paraphrenia 174Phonemic Paraphrenia 179Incoherent Paraphrenia 185Fantastic Paraphrenia 191Confabulatory Paraphrenia... 199Expansive Paraphrenia 206

Review of the Family Picture of Systematic Paraphrenias 214Final Remarks on the Simple Systematic Forms of Schizophrenia 215

Combined Systematic Schizophrenias 216Combined Systematic Catatonias 216Combined Systematic Hebephrenias 224Combined Systematic Paraphrenias 227Family Picture of Combined Systematic Schizophrenias 247

Comments 248

Age of Onset, Sex Incidence, Course 250Statistical Findings from Investigations before 1968 250

Age of Onset, Sex Incidence, and Number of Phases in thePhasic Psychoses (Including the Cycloid) 250Incidence of Psychoses in the Families of Phasic Psychoses(Including the Cycloids) 259Summary: Principal Findings in Phasic (Including Cycloid)Psychoses 261Age of Onset, Sex Incidence, and Course in the Schizophrenias(Investigations before 1968) 263Number of Psychoses in the Families of Schizophrenics 269

Statistical Findings from Investigations after 1968 271

The Question of Endogenous Mixed Psychosis 275

Etiology of Endogenous Psychoses 278Significance of Hereditary Disposition 279Significance of Psychosocial Circumstances 283

Lack of Communication in the Development ofSystematic Schizophrenias 285

Absence of Systematic Schizophrenias in Monozygotic Twins.. 285Lack of Communication in Systematic Schizophreniaof Childhood 288Siblings of Patients with Systematic Schizophrenias 290Prophylaxis of Systematic Schizophrenias................ 299

Table of Contents XXI

Exogenous and Constitutional Causes of the UnsystematicSchizophrenias 301

Periodic Catatonia 301Mfective Paraphrenia 308Cataphasia 310

Exogenous and Constitutional Causes of Cycloid Psychoses 313Exogenous and Constitutional Causes of Manic-DepressiveIllness 321Exogenous and Constitutional Causes of Pure Phasic Psychoses . 324

Early Childhood Catatonia 330Delineation of Early Childhood Catatonia... 330The Question of Organicity Underlying the Clinical Picture 331Diagnosis of Childhood Schizophrenia. 332Distribution oflndividual Forms of Early Childhood Catatonia .. 337Distinguishing Early Childhood Catatonia fromMental Retardation 338Clinical Pictures of Early Childhood Catatonia 340

Simple Systematic Catatonia of Early Childhood 341Combined Systematic Catatonia of Early Childhood 355

Etiology of Early Childhood Schizophrenia. 366Psychosocial Causes 367Role of Heredity 377Prophylaxis of Early Childhood Catatonia .. 382Therapeutic Feasibility in Early Childhood Catatonia 383

Karl Leonhard's Life (1904-1988) 387

References 389

Appendix 393

Subject Index....... 395