Tracing the Roots of Dementia Praecox: The Emergence of Verrücktheit as a Primary Delusional-Hallucinatory Psychosis in German Psychiatry From 1860 to 1880.

While the roots of mania and melancholia can be traced to the 18th century and earlier, we have no such long historical narrative for dementia praecox (DP). I, here, provide part of that history, beginning with Kraepelin's chapter on Verrücktheit for his 1883 first edition textbook, which, over the ensuing 5 editions, evolved into Kraepelin's mature concepts of paranoia and paranoid DP. That chapter had 5 references published from 1865 to 1879 when delusional-hallucinatory syndromes in Germany were largely understood as secondary syndromes arising from prior episodes of melancholia and mania in the course of a unitary psychosis. Each paper challenged that view supporting a primary Verrücktheit as a disorder that should exist alongside mania and melancholia. The later authors utilized faculty psychology, noting that primary Verrücktheit resulted from a fundamental disorder of thought or cognition. In particular, they argued that, while delusions in mania and melancholia were secondary, arising from primary mood changes, in Verrücktheit, delusions were primary with observed changes in mood resulting from, and not causing, the delusions. In addition to faculty psychology, these nosologic changes were based on the common-sense concept of understandability that permitted clinicians to distinguish individuals in which delusions emerged from mood changes and mood changes from delusions. The rise of primary Verrücktheit in German psychiatry in the 1860-1870s created a nosologic space for primary psychotic illness. From 1883 to 1899, Kraepelin moved into this space filling it with his mature diagnoses of paranoia and paranoid DP, our modern-day paranoid schizophrenia.

The Genealogy of Dementia Praecox I: Signs and Symptoms of Delusional Psychoses From 1880 to 1900.

We can trace, with high congruence, the clinical syndromes of depression and mania as described over the 20th century in psychiatric textbooks back to 1880 and to the earliest writing of Kraepelin published in 1883. However, this is not the case for Kraepelin's 2 delusional syndromes central to his overall nosology: Dementia Paranoides (later paranoid schizophrenia) and Paranoia. A detailed examination of 28 textbook descriptions of delusional psychoses from 1880 to 1900 reveals a diverse and partially overlapping set of syndromes with an admixture of symptoms and signs that would later be considered indicative of Dementia Paranoides and Paranoia. A similar pattern in seen in Kraepelin's own description of "Primäre Verrücktheit" from the first edition of his textbook (1883). No clear prototypes emerged in these textbooks or in Kraepelin's early writings for the 2 distinct delusional syndromes that would later evolve in his mature writings. Rather, the nosologic approach taken in these writings was symptom based and assumed that a viable diagnostic category could be constituted by including all delusional patients once those suffering from organic or mood disorders were excluded. While Kraepelin used the historical syndromes of mania and depression, with no appreciable change, as building blocks for his category of manic-depressive insanity, his nosologic system for the psychotic disorders-the syndromes of Dementia Praecox and Paranoia-was more innovative and without clear precedent in the prior psychiatric literature.

Symptom rating scales for schizophrenia and other primary psychotic disorders in ICD-11.

The subtype system for categorising presentations of schizophrenia will be removed from International Classification of Diseases 11th Revision. In its place will be a system for rating six domains of psychotic disorder pathology: positive symptoms, negative symptoms, depressive symptoms, manic symptoms, psychomotor symptoms and cognitive symptoms. This paper outlines the rationale and description of the proposed symptom rating scale, including current controversies. In particular, the scale could adopt either a 4-point severity rating or a 2-point presence/absence rating. The 4-point scale has the advantage of gathering more information, but potentially at the cost of reliability. The paper concludes by describing the field testing process for evaluating the proposed scale.

Transdiagnostic Extension of Delusions: Schizophrenia and Beyond.

Delusion is central to the conceptualization, definition, and identification of schizophrenia. However, in current classifications, the presence of delusions is neither necessary nor sufficient for the diagnosis of schizophrenia, nor is it sufficient to exclude the diagnosis of some other psychiatric conditions. Partly as a consequence of these classification rules, it is possible for delusions to exist transdiagnostically. In this article, we evaluate the extent to which this happens, and in what ways the characteristics of delusions vary according to diagnostic context. We were able to examine their presence and form in delusional disorder, affective disorder, obsessive-compulsive disorder, borderline personality disorder, and dementia, in all of which they have an appreciable presence. There is some evidence that the mechanisms of delusion formation are, at least to an extent, shared across these disorders. This transdiagnostic extension of delusions is an argument for targeting them therapeutically in their own right. However there is a dearth of research to enable the rational transdiagnostic deployment of either pharmacological or psychological treatments.

Vive La France: Three Delusional Disorders Originally Reported in the French Medical Literature.

Delusions as a feature of psychosis have long captured the fascination of both psychiatry and the public at large. The French first described three famous delusions: the Cotard delusion, folie à deux, and Capgras delusion. In this article, we examine a case illustrating each delusion and the hallmark features of each as well as a brief discussion about the current understanding of these disorders.

Psychotic disorders in DSM-5 and ICD-11.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was published by the American Psychiatric Association (APA) in 2013, and the Work Group on the Classification of Psychotic disorders (WGPD), installed by the World Health Organization (WHO), is expected to publish the new chapter about schizophrenia and other primary psychotic disorders in 2017. We reviewed the available literature to summarize the major changes, innovations, and developments of both manuals. If available and possible, we outline the theoretical background behind these changes. Due to the fact that the development of ICD-11 has not yet been completed, the details about ICD-11 are still proposals under ongoing revision. In this ongoing process, they may be revised and therefore have to be seen as proposals. DSM-5 has eliminated schizophrenia subtypes and replaced them with a dimensional approach based on symptom assessments. ICD-11 will most likely go in a similar direction, as both manuals are planned to be more harmonized, although some differences will remain in details and the conceptual orientation. Next to these modifications, ICD-11 will provide a transsectional diagnostic criterion for schizoaffective disorders and a reorganization of acute and transient psychotic and delusional disorders. In this manuscript, we will compare the 2 classification systems.

[Schizophrenia or a group of endogenous diseases? The past and the present].

A critical analysis of the main concepts of schizophrenia (from the Kraepelin paradigm to the current studies attempted to «destruct¼ schizophrenia as nosologically independent disease) is presented. In author's opinion, the elimination of schizophrenia may lead to negative consequences as in aspect of clinical practice (the diagnosis of schizophrenia provides information about disease course, clinical and social outcomes) as well as in aspect of denial of autochthonous (endogenous) origin of mental disorders that fall under this definition. Based on the current level of knowledge, manifestation of these disorders can't be well explained by the adverse effects of situational, psychogenic or somatogenic factors. The restriction of the definition of schizophrenia («process¼ schizophrenia) should be brought about by the elimination of a group of schizophrenia spectrum disorders (schizotypal disorder, schizoaffective disorder, delusional psychosis).

Psy-feld: An Innovative Didactic Using the TV Show Seinfeld to Teach Delusional Disorder Subtypes.

OBJECTIVE: The primary purpose of this article is to introduce Psy-feld, an innovative didactic used to review mental disorders through discussion of the interpersonal relationships of the fictional characters created in Larry David's situational comedy, Seinfeld. To introduce this novel didactic, several peripheral Seinfeld characters were selected, who while not afflicted with a psychotic disorder, demonstrate traits that serve to facilitate discussion to review the different subtypes of Delusional Disorder. METHODS: Psy-feld is a 30-min faculty-facilitated didactic where a selected episode of the sitcom allows for review of multidisciplinary content areas considered germane to the practice of psychiatry. At Rutgers-Robert Wood Johnson Medical School, 104 third-year medical students rotated on the Consultation-Liaison Service from July 2011-March 2014 and participated in Psy-feld. RESULTS: Of the 104 students who participated in Psy-feld, 99 completed surveys on the didactic. Students found the didactic to be of high quality, believed it enhanced their learning, and thought that it prepared them for their final SHELF exam. Students also found it enjoyable and preferred the didactic to more traditional forms of teaching such as large group lectures. CONCLUSIONS: Psy-feld is an example of an innovative teaching method that medical students found informative in reviewing teaching points of Delusional Disorder.

The masks of identities: who's who? Delusional misidentification syndromes.

Delusional misidentification syndromes (DMSs) are complex psychotic phenomena that may be present in a variety of ways within the context of several neurological and psychiatric disorders. Since the first case of Capgras syndrome was described in 1923, various other syndromes have been identified, including Fregoli syndrome, intermetamorphosis, subjective doubles, reduplicative paramnesia, mirrored self, delusional companions, and clonal pluralization of the self. In this article, we review each of the different syndromes in definition and presentation, as well as the field's attempts at classifying them. We then describe their role in forensic psychiatry, particularly in regard to their potential as a marker of a particular subpopulation or of illness severity and their consideration in risk assessments of violence. A review of the literature was conducted for this purpose, and, although it was extended to include publications from over four decades, it revealed a paucity of research on DMSs.

[The schizophrenia spectrum and other psychotic disorders in the DSM-5]. / Schizofreniespectrum en andere psychotische stoornissen in de DSM-5.

BACKGROUND: This article discusses changes made in the diagnostic criteria for psychotic disorders in the transition from DSM-IV to DSM-5. AIM: To review and evaluate the changes incorporated in the DSM-5 criteria for psychotic disorders. METHOD: Relevant documents and proceedings were reviewed on the basis of personal experience in the APA working group on psychotic disorders. RESULTS: The chapter on the 'schizophrenia spectrum and other psychotic disorders' in DSM-5 introduces a conceptual psychosis continuum, in which the level, number and duration of psychotic signs and symptoms are used to differentiate between various forms of psychotic disorders. The chapter includes only a few marginal adjustments, aimed at simplifying usage and measurement-based treatment. The DSM-5 Committee also aspired for harmonization with the ICD. The Committee was in favor of a new name for schizophrenia, but referred the matter to the WHO. The empirical basis for 'attentuated psychosis syndrome' was found to be insufficient for the syndrome to be included as a diagnosis. The most important changes in the criteria for schizophrenia are the elimination of the classic subtypes, the clarification of cross-sectional and longitudinal course specifiers, the elimination of special status of Schneiderian first-rank symptoms, and the clarification and better delineation of schizophrenia in terms of: a) the relationship between schizophrenia and schizoaffective disorders and b) the relationship between schizophrenia and catatonia. In schizoaffective disorder, the perspective shifts from an episode diagnosis in DSM-IV to a life course for the illness in DSM-5. Although the committee gave serious consideration to the inclusion of trans-diagnostic dimensions, these have not been included; a factor that precludes more personalised diagnoses, at least for the time being. CONCLUSION: The limitations of the classic system of categorical diagnosis are widely acknowledged and serious consideration has been given to the abolition of this type of diagnosis or at least to the possibility of enriching it with a transdiagnostic focus on dimensions of psychopathology. These steps have not been taken in DSM-5 - for the consensus committees this is evidently still a bridge too far.

Delusional disorder as a partial psychosis.

In his textbook from 1838, Esquirol made the first comprehensive psychopathological description of paranoia, which he labeled partial psychosis. This was a condition with encapsulated, well organized, and persistent delusions. These are defended with a great deal of emotions and sharp argument. The individual appears quite convincing, especially because he or she otherwise behaves rationally. The intellectual capacity is used to achieve defined goals according to the delusional content. This condition is difficult to uncover because of dissimulation and adaptation. The frequency in the population is unknown, but the condition is rare in psychiatric treatment facilities, and usually only when the persons become litigious or criminal. In Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the condition is covered by the concept of delusional disorder, but that concept also comprises benign acute/subacute conditions as well as cases that turn out to have the diagnosis changed to schizophrenia.

Psychotic disorders in DSM-5: summary of changes.

Key issues related to the diagnosis of schizophrenia and other psychotic disorders addressed in DSM-5 were more precisely defining diagnostic boundaries between different psychotic disorders, reducing spurious comorbidity, improving coherence across the diagnostic manual, and enhancing validity without loss of reliability. New information about the nature of these disorders generated since DSM-IV was incorporated into their definition. Resulting changes in DSM-5 include elimination of the classic subtypes of schizophrenia, elimination of special treatment of Schneiderian 'first-rank symptoms', more precise delineation of schizoaffective disorder from schizophrenia and psychotic mood disorders, and clarification of the nosologic status of catatonia and its consistent treatment across the manual. Changes in section 3 of the manual include addition of a new category of "attenuated psychosis syndrome" as a condition for further study and addition of unique psychopathological dimensions (that represent treatment targets across disorders). The specific nature of these revisions in the DSM-5 criteria for schizophrenia and other psychotic disorders along with their rationale are summarized in this article.

Schizophrenia and other psychotic disorders in DSM-5.

Whereas improving validity and reliability of psychiatric diagnoses were key objectives in the development of DSM-5, enhancing clinical utility was the primary goal. With reference to psychotic disorders, changes addressed limitations in DSM-IV while incorporating new information about the nature of these disorders generated over the past twenty years. With regard to schizophrenia, variation in distinct psychopathological dimensions has been found to better account for the heterogeneity of schizophrenia than traditional subtypes. Resulting changes in DSM-5 will likely include elimination of the classic subtypes of schizophrenia and addition of unique psychopathological dimensions, along with elimination of the special treatment of Schneiderian "first-rank symptoms." In view of the poor reliability and limited validity of DSM-IV schizoaffective disorder, a clearer definition is provided in DSM-5. Considering the discrepant treatment of catatonia in DSM-IV, it is treated consistently across the DSM-5 manual. Minor changes are made in the definition of delusional disorder to reduce spurious comorbidity and unnecessary complexity. A new category of "attenuated psychosis syndrome" is included in the appendix as a condition for further study. In this article, major likely revisions in the DSM-5 (due to be published in May 2013) criteria for schizophrenia spectrum and other psychotic disorders are summarized and their implications for clinical practice are discussed.

Classifying psychosis--challenges and opportunities.

Within the efforts to revise ICD-10 and DSM-IV-TR, work groups on the classification of psychotic disorders appointed by the World Health Organization (WHO) and the American Psychiatric Association (APA) have proposed several changes to the corresponding classification criteria of schizophrenia and other psychotic disorders in order to increase the clinical utility, reliability and validity of these diagnoses. These proposed revisions are subject to field trials with the objective of studying whether they will lead to an improvement of the classification systems in comparison to their previous versions. Both a challenge and an opportunity, the APA and WHO have also considered harmonizing between the two classifications. The current status of both suggests that this goal can only be met in part. The main proposed revisions include changes to the number and types of symptoms of schizophrenia, the replacement of existing schizophrenia subtypes with dimensional assessments or symptom specifiers, different modifications of the criteria for schizoaffective disorder, a reorganization of the delusional disorders and the acute and transient psychotic disorders in ICD-11, as well as the revision of course and psychomotor symptoms/catatonia specifiers in both classification systems.

[Paranoia and persecution]. / Paranoia et persécution.

The idea of paranoia has existed since Antiquity, but it was only in the 19th centurythat psychiatrists became interested in it and sought to describe it. Delusion and the feeling of persecution are common in all paranoiacs. The origins of the disease can be found in the patient's psychic structure. Establishing and maintaining contact with a caregiver is one way of helping the patient.

Delusional disorders--are they simply paranoid schizophrenia?

OBJECTIVES: This article tries to give an answer to the question of whether International Classification of Diseases (ICD-10) persistent delusional disorder (PDD) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) delusional disorder (DD) is simply paranoid schizophrenia (PS). Because ICD-10 PDD and DSM-IV DD are identical, we use DD as a synonym. METHODS: A prospective and longitudinal study compared all inpatients with DD treated at the Halle-Wittenberg university hospital during a 14-year period with a previously investigated selected cohort of patients with PS. Sociodemographic data, symptomatology, course, and outcome parameters were examined using standardized instruments. The duration of the follow-up period in patients with DD was 10.8 years and for the PS patients 12.9 years. RESULTS: Significant differences between DD and PS were found: DD patients are, in comparison to patients with PS, significantly older at onset. Less of their first-degree relatives have mental disorders. They less frequently come from a broken home situation. First-rank symptoms, relevant negative symptoms, and primary hallucinations did not occur in patients with DD. Patients with DD were less frequently hospitalized, and the duration of their hospitalization was shorter. Their outcome is much better regarding employment, early retirement due to the disorder, and psychopharmacological medication. They more often had stable heterosexual partnerships and were autarkic. They had lower scores in the Disability Assessment Scale and in Positive and Negative Syndrome Scale. The diagnosis of DD is very stable over time. CONCLUSIONS: The findings of this study support the assumption that DDs are a separate entity and only exceptionally can be a prodrome of schizophrenia.

[Portuguese translation of Alistair Munro's criteria for paraphrenia]. / Tradução para português dos critérios de Alistair Munro para parafrenia.

The current concept of paraphrenia has its historical origins in Emil Kraepelin's work. Several factors, however, contributed to the fading out of this disorder, namely the follow-up study of W. Mayer, the influences of Bleuler and of some related concepts, such as Roth's late paraphrenia. Over the last decades Alistair Munro and co-workers have contributed to the clarification and precision of the paraphrenia concept. One of the essentials steps was to come up with a specific set of diagnostic criteria, which are presented here translated to Portuguese.

[Operationalized psychodynamic diagnostics (OPD) in patients in a prodromal state of schizophrenia--an explorative study]. / Operationalisierte Psychodynamische Diagnostik (OPD) bei Patienten im schizophrenen Prodromalstadium--Eine explorative Studie.

OBJECTIVES: To obtain data and hypotheses regarding the amelioration of risk estimation and preventive psychotherapy in patients in a prodromal state of schizophrenia by using OPD. METHODS: 20 participants with a prodromal condition--6 subjects far from psychosis and 14 close to psychosis--along with 10 patients with paranoid schizophrenia as reference group were examined using the first four OPD axes. RESULTS: Both groups differed considerably in all four axes. Compared to the schizophrenic participants, prodromal probands appear to have more favourable preconditions for therapy. Moreover, they experienced the interaction partners, including the investigator, as less aversive and induced less distanced behaviour in the investigator. Conflicts of self-esteem were prominent in both prodromal subgroups. However, patients farther from psychosis showed less conflicts of autonomy versus dependence and displayed a higher integration in structures such as "defence" and "attachment" when compared to participants closer to psychosis. CONCLUSIONS: Particularly the differences between the prodromal subgroups suggest that application of the OPD may positively complement previous approaches of early detection, prevention,and psychotherapy for prodromal conditions. The hypotheses obtained should be tested in longitudinal studies with larger sample sizes.