Reshaping the diagnostic borders: Historical analysis of the diagnostic changes following the introduction of the schizophrenia concept.

BACKGROUND: Although the concept of schizophrenia is still widely presented as having replaced that of dementia praecox, studies have shown that the former was broader than the latter, resulting in a more complex diagnostic redistribution. However, this is poorly documented by quantitative approaches. AIMS: We sought to test the hypothesis that the use of the concept of schizophrenia had caused a diagnostic redistribution and to quantify it. METHOD: A retrospective study, based on admission register archives of the Strasbourg University Clinic of Psychiatry was conducted. The frequency of diagnoses given to patients were examined at two key time periods: one before (TP1) and one after (TP2) the introduction of the schizophrenia concept (established between 1926 and 1928). Eight main diagnoses related to schizophrenia were considered. RESULTS: Patients diagnosed with schizophrenia at TP2 mainly received the diagnoses of dementia praecox but also depression, hebephrenia, manic depressive illness, hysteria, paraphrenia, catatonia and mania at TP1. Dementia praecox and hebephrenia were the most relayed by schizophrenia. Bayesian sensitivity analyses confirmed the robustness of our data against distinct scenarios challenging our hypothesis. CONCLUSIONS: Our results confirm the broadening of the concept of schizophrenia compared to that of dementia praecox but also qualify the different concepts supposed to have been impacted. They provide unique quantitative data that define the contours of the diagnostic redistribution thus provoked. They also give relevant input in the current context where the need to rethink the DSM/ICD concept of schizophrenia is still debated.

One hundred and fifty years of hebephrenia. A review.

INTRODUCTION: The publication of Hecker's article on hebephrenia in 1871 was a fundamental milestone for clinical psychiatry. Despite the initial recognition, many voices were raised against this diagnostic category and its limits were attenuated throughout the 20th century until its disappearance at the beginning of this century (along with the other subtypes of schizophrenia) in the DSM and ICD. DISCUSSION: However, given the consistency of the clinical picture, there is the possibility of other criteria emerging that would lead its systematic study to continue or recommence. In this sense, the concepts of deficit schizophrenia, hebephrenia as a replacement for schizophrenia as a whole, and Leonhard's hebephrenias as systematic schizophrenias stand out. This article discusses the main diagnostic conflicts of the category of hebephrenia over time, with emphasis on the problems of recent decades. CONCLUSIONS: The concept of hebephrenia has begun to be revalued in recent years, and the concepts of deficit schizophrenia, of hebephrenia as a major category, and of systematic hebephrenias allow further investigation of this foundational picture of clinical psychiatry.

'Acquired idiotism', by Frederik Lange (1883).

The little-known writing by Frederik Lange translated in this Classic Text belongs to what can be called the prolegomenal history of the construction of the concept of schizophrenia. It describes one effort to capture the convergence of certain words of diverse coinage (dementia praecox, acquired idiocy, hebephrenia, heboidophrenia, etc.) with some newly accepted concepts (e.g. the temporalization of madness and the view that adolescence was an independent period of life), and with some old behaviours (which for centuries had been called madness, the portmanteau soon to be rebaptized as psychosis). This convergence culminated in the work of Kraepelin, who was to call it 'dementia praecox'. Lange's transitional efforts and pangs can be sensed as he struggles to describe a new form of madness that affects young people.

An overview on Hebephrenia, a diagnostic cornerstone in the neurodevelopmental model of Schizophrenia.

Pre-Kraepelinian observations converged in Kahlbaum's and Hecker's description of Hebephrenia. For Kraepelin, Hebephrenia was an 'idiopathic incurable dementia whose onset is in adolescence'. It became the core of 'Dementia Praecox', and then Bleulerian 'Schizophrenia'. In recent decades, the resurgence of the 'late neurodevelopment' hypothesis of schizophrenia has brought into focus Hecker's clinical reports of adolescents who, as a result of a putative loss of psychic energy, showed a rapidly progressive cognitive impairment leading to functional and behavioural disorganization. This paper summarizes the nineteenth-century conceptualization of Hebephrenia as a developmental illness.

Parietal lobe and disorganisation syndrome in schizophrenia and psychotic bipolar disorder: A bimodal connectivity study.

Given the emerging evidence in support of parietal brain stimulation to treat speech disorder in psychosis, we investigated structural and functional parietal dysconnectivity in schizophrenia (n = 34) and bipolar disorder with psychotic symptoms (n = 16). We found that both patient groups demonstrated reduced left parietal structural connectivity compared to healthy controls (n = 32). The three groups also differed significantly on the variability of left and right parietal dynamic functional connectivity. In patients with schizophrenia, parietal dysconnectivity predicted the severity of disorganisation symptoms. These findings suggest that dysconnectivity between the parietal lobe and the rest of the brain plays a key role in disorganisation symptoms of schizophrenia.

The development of Kraepelin's mature diagnostic concept of hebephrenia: a close reading of relevant texts of Hecker, Daraszkiewicz, and Kraepelin.

In developing his mature concept of hebephrenic dementia praecox (DP) in his 4th (1893) through 6th textbook editions (1899), Kraepelin worked from the hebephrenic syndrome first described by Hecker (1871) and then carefully studied by his student Daraszkiewicz (1892). Working under Kraepelin's supervision, Daraszkiewicz followed Hecker in emphasizing several key features of hebephrenia (distinctive deteriorative course, importance of silliness and minimal positive psychotic symptoms) but expanded the syndrome to include cases developing severe dementia, rejected the link to prodromal depressive and manic phases, and reduced the emphasis on thought disorder. Daraszkiewicz proposed a soft subtyping of hebephrenia based on level of deterioration, which Kraepelin adopted in his 4th edition with an additional emphasis on severe positive psychotic symptoms. In his 5th edition, Kraepelin created a third subform with even more pronounced and bizarre delusions and hallucinations. In his 6th edition, which contained his first articulation of DP, Kraepelin eliminated his hebephrenia subforms presenting a single syndrome, which, compared to Hecker, included more emphasis on positive psychotic and catatonic symptoms and severe dementia. Kraepelin's paths to hebephrenic and paranoid DP differed in important ways. Paranoid DP was a de novo syndrome created by differentiation from paranoia. Hebephrenia, by contrast, evolved from a disorder created in the Kahlbaum/Hecker paradigm of the iterative study of clinical features, course and outcome. Kraepelin further implemented this approach in substantially reworking, over several drafts, the hebephrenic syndrome to fit into his emerging construct of dementia praecox.

Heboidophrenia and Pseudo-Psychopathic Schizophrenia: Current Knowledge and Critical Perspective.

In this article, based on literature review, we present an integrated description of heboidophrenia and pseudo-psychopathic schizophrenia. Both diagnostic constructs describe latent psychotic processes inextricably bound with psychopathic features. Although both have been described in different eras and research threads, they are that similar that we could not find divergences. We formulated operational criteria for clinical and research purpose. The recognition of this syndrome improves risk management, treatment, and legal decisions.

The healthy side of positive schizotypy may reflect positive self-report biases

The concept of healthy schizotypy, characterized by positive schizotypy symptoms in the absence of negative or disorganized schizotypy, raises questions regarding whether the contrast between its healthy appearance and its relatively high level of impairment might be due to self-reported advantages. Using cluster analysis, we aimed at typifying a positive schizotypy group in a large nonclinical sample of young adults to examine its association with depressive symptoms, cannabis use, academic performance, well-being and serendipity, while controlling for variables inducing positive self-report biases: self-deceptive denial, wishful thinking, social desirability and narcissistic traits. We thus identified a pure positive schizotypy cluster (P) and a positive and disorganized cluster (PD) which had the highest level of the positive factor. Both clusters were characterized by a contrast between a high level of well-being, life satisfaction and self-reported serendipity (similar to a low schizotypy cluster) with elevated level of impairment markers (lower academic performance, higher depressive symptoms and cannabis use), comparable with clusters high in negative schizotypy. Moreover P and PD had elevated levels of variables susceptible to induce positive self-report biases (denial, wishful thinking, social desirability, narcissistic traits), while the clusters high in negative schizotypy had lower levels. We conclude that the relative high level of well-being and life satisfaction observed in groups with elevated positive and low negative schizotypy may in fact be linked to positive self-report biases (AU)

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[Hebephrenia - a viable psychopathological construct?] / Hebephrenie ­ ein brauchbares psychopathologisches Konstrukt?

Ewald Hecker was the first psychiatrist to describe the disease entity of hebephrenia in some detail, focusing mainly on disturbances of affect. Later Emil Kraepelin and Eugen Bleuler saw hebephrenia as a subtype of dementia praecox or schizophrenia. Willy Mayer-Gross and Karl Leonhard characterized hebephrenia with highly differentiated psychopathological descriptions, whereas this construct only played a minor role in the works of Klaus Conrad and Kurt Schneider. The International Classification of Diseases (ICD-10) lists hebephrenia as a subtype of schizophrenia but in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) no subtypes of schizophrenia are mentioned and the concept of hebephrenia is thus lost. Hebephrenia can be seen as an ideal type describing a psychopathological course pattern. This construct can be useful to conceptualize a group of disorders of affect which otherwise escape description, especially since these psychopathological alterations of affect are difficult to operationalize. To have a viable concept of these disorders is relevant for the prognosis and therapy planning. If the concept of hebephrenia is abolished, important psychopathological knowledge might be lost for future generations of psychiatrists.

Psicosis de transferencia en la psicoterapia de la esquizofrenia crónica / Transference psychosis in the psychotherapy of chronic schizophrenia / Psychose de transfert dans la psychothérapie de la schizophrénie chronique

El autor, partiendo de su experiencia en la psicoterapia con pacientes esquizofrénicos ingresados en una institución, expone su modo de entender los movimientos transferenciales psicóticos, así como el modo en que el analista es convocado en su contratransferencia. Define cuatro modalidades: una primera en la que, partiendo de lo presimbiótico en Mahler, habla de relaciones autísticas en que la investidura no es humana o resulta inanimada o muy parcializada; una segunda en la que el vínculo es simbiótico y altamente ambivalente; una tercera, en la que los movimientos hacia la autonomía o independencia del sujeto se viven como ataques al objeto; y una cuarta en la que la confusión predomina en la relación y el objeto tiene que hacerse cargo del pensamiento del sujeto. Todo ello es ilustrado ampliamente por material clínico y puesto en discusión sobre todo con autores como Bion, Rosenfeld y Little

Drawing upon his experience in psychotherapy with schizophrenic inpatients, the author sets out his understanding of psychotic transference movements, and the way in which the analyst is summoned in his countertransference. He defines four modalities: a first, in which, drawing upon the pre-symbiotic in Mahler, he discusses autistic relationships in which investment is not human, or is inanimate or very partialized; a second, in which the link is symbiotic and highly ambivalent; a third, in experienced as attacks on the object; and a fourth, in which confusion predominates in the relationship and the object must take on the subject's thinking. All of this is extensively illustrated by clinical material and discussed primarily with authors such as Bion, Rosenf eld and Little

L' auteur, partant de son expérience dans la psychothérapie avec des patients schizophrenes hospitalisés en institution, expose sa façon de comprendre les mouvements transf érentiels psychotiques, ainsi que la façon dont l' analyste est convoqué dans son contretransfert. Il définit quatre modalités: la premiere, ou en partant du pré-symbiotique de Mahler, il parle de relations autistiques ou l'investissement n'est pas humain ou bien résulte inanimé ou tres partiel; une deuxieme, ou le lien est symbiotique et hautement ambivalent; une troisieme, ou les mouvements vers l' autonomie ou l'indépendance du su jet sont vécus comme des attaques al' objet, et une quatrieme, ou la confusion prévaut dans la relation et l'objet doit prendre en charge la pensée du sujet. Tout ceci est illustré largement par du matériel clinique et discuté surtout avec des auteurs tels que Bion, Rosenfeld et Little

Disorganised schizotypy is selectively associated with poorer semantic processing in non-clinical individuals.

The nature and severity of semantic memory (SM) impairments in schizophrenia has been related to symptoms, mainly formal thought disorder (FTD), and other clinical factors like length of illness. Symptom-related studies in schizophrenia are often confounded by clinical factors, for example medication and hospitalisations. We completed a schizotypy analogue study to examine the relationship between SM processing and FTD using an analogue schizotypy score referred to as cognitive disorganisation. Sixty individuals without a history of mental illness (M=22.92, SD=2.70) completed a schizotypy questionnaire and three semantic tasks - naming pictures, category fluency and semantic priming. Only decreasing fluency was associated with increasing cognitive disorganisation scores (p=0.029). In line with the prevailing dyssemantic theories, the results highlight that cognitive disorganisation is associated with some difficulties in SM processes, though not all. The observed differential relationships of SM processes to disorganised schizotypy are discussed in relation to previous work, and in terms of potential developmental trajectories for SM impairment in schizophrenia.

The Curse of the Dolphins: Cognitive Decline and Psychosis.

CASE: Isela is an 11-year-old Mexican-American girl with mild intellectual disability. During a vacation with her family, she went swimming with dolphins. A few days later, Isela awoke at night with laughing spells; during the day, she was pacing, aggressive, and had a decline in self-care and communication skills. Her parents attributed the symptoms to the dolphins. She was evaluated by a pediatric neurologist. The sleep-deprived electroencephalogram, brain magnetic resonance imaging, lumbar puncture, and thyroid function tests were normal. A genomic microarray was sent. The neurologist initiated empirical therapy for seizures with lamotrigine, which caused a rash. It was discontinued. She was then treated with oxcarbazepine followed by topiramate for several months without any change in symptoms. Comparative genomic hybridization revealed a small deletion at 14q13.1, which includes the NPAS3 gene. Psychiatry was consulted after several months of persistent symptoms. Isela seemed to be laughing in response to internal stimuli. Owing to the decline in communication and her apparent preoccupation with visual and auditory internal stimuli, Isela could not be interviewed adequately to confirm that she was experiencing hallucinations, but her laughter seemed to be in response to hallucinations. Isela was diagnosed with disorganized schizophrenia with psychosis. Risperidone was prescribed. A psychology evaluation was completed a few months later. Parents noted significant improvement after starting risperidone with reduced inappropriate laughing spells, reduced pacing, as well as improved eating, sleeping, communication, and self-care. Cognitive assessment with the Wechsler Abbreviated Scale of Intelligence-II indicated the following: verbal estimated intelligence quotient (IQ) = 70, perceptual estimated IQ = 71, and full-scale estimated IQ = 68. There was no cognitive decline compared with testing at school 4 years previously. Although psychotic symptoms were significantly improved on antipsychotic medication and function appeared to have been restored to her previous level, her parents continued to perceive a significant decline of functioning, and they continued to attribute the psychosis to swimming with the dolphins.

Prevalence of aggression in hospitalized patients with schizophrenia in China: A meta-analysis.

INTRODUCTION: Aggression is a major concern in psychiatric inpatient care. Variations in study designs, settings, populations and data collection methods render comparisons of the prevalence of aggressive behavior in high-risk settings difficult. We proposed to estimate the pooled prevalence of aggression among inpatients with schizophrenia in China. METHODS: Reports on aggressive behaviour involving physical contact or risks of interpersonal violence, in schizophrenia in Chinese general psychiatric wards were retrieved by using computer-assisted searches and manual searches of the reference lists of the relevant literature. Statistical analyses were conducted using the Comprehensive Meta-Analysis V2 software. Potential sources of heterogeneity were analyzed with Cochrane's Q analysis. RESULTS: The search yielded 19 eligible studies involving a total of 3,941 schizophrenia patients. The prevalence of aggressive behavior in psychiatric wards ranged between 15.3% and 53.2%. The pooled prevalence of aggression was 35.4% (95% CI: 29.7%, 41.4%). The most commonly reported significant risk factors for aggression were positive psychotic symptoms: hostility or suspiciousness, 78.9% (15 studies); delusions, 63.2% (12 studies); disorganized behavior, 26.3% (5 studies); and auditory hallucinations, 10.5% (2 studies); together with: past history of aggression, 42.1% (8 studies); and involuntary admission, 10.5% (2 studies). CONCLUSIONS: Aggressive behaviour is common in Chinese inpatients with schizophrenia. The prevalence figures indicate the need to identify reliable clinical and illness predictors for aggression in inpatient psychiatric wards and to test investigations aimed at reducing aggressive episodes and their adverse outcomes.

Correlation between neuropsychological and social cognition measures and symptom dimensions in schizophrenic patients.

Neurocognitive and social cognition deficits have been largely reported in Schizophrenia (SKZ) but their association with psychopathology remains uncertain. Our purpose was to explore the relationship between symptom dimensions and neuropsychological performances. We enrolled 35 stabilized schizophrenic outpatients of the Department of Psychiatry of Policlinico Hospital, University of Milan, who completed psychiatric Rating Scales, the Brief Assessment of Cognition in Schizophrenia (BACS) and the Executive and Social Cognition Battery (ESCB). Disorganized dimension seems to have the most significant impact on cognition, being associated with performance in several BACS subtests (verbal memory, working memory, motor speed, symbol coding, Tower of London) and ESCB tasks (MET and Hotel task number of tasks attempted, number of broken MET rules, sum of deviations in Hotel Task). Positive dimension correlated with performance in verbal fluency, negative dimension with IOWA Test results, cognitive dimension with MET number of inefficiencies and Eyes test score. Impulsive-aggressive and depressive dimensions weakly correlated only with Faux Pas test. Our study supports the existence of a specific disorganized dimension in SKZ, separated from cognitive dimension evaluated through clinical instruments (e.g. PANSS), but capable of influencing cognitive abilities. Furthermore, it strengthens the validity of ecological tasks in evaluating cognition in SKZ.

Childhood neglect predicts disorganization in schizophrenia through grey matter decrease in dorsolateral prefrontal cortex.

OBJECTIVE: Psychosocial trauma during childhood is associated with schizophrenia vulnerability. The pattern of grey matter decrease is similar to brain alterations seen in schizophrenia. Our objective was to explore the links between childhood trauma, brain morphology and schizophrenia symptoms. METHOD: Twenty-one patients with schizophrenia stabilized with atypical antipsychotic monotherapy and 30 healthy control subjects completed the study. Anatomical MRI images were analysed using optimized voxel-based morphometry (VBM). Childhood trauma was assessed with the Childhood Trauma Questionnaire, and symptoms were rated on the Scale for the Assessment of Negative Symptoms (SANS) and Scale for the Assessment of Positive Symptoms (SAPS) (disorganization, positive and negative symptoms). In the schizophrenia group, we used structural equation modelling in a path analysis. RESULTS: Total grey matter volume was negatively associated with emotional neglect (EN) in patients with schizophrenia. Whole-brain VBM analyses of grey matter in the schizophrenia group revealed a specific inversed association between EN and the right dorsolateral prefrontal cortex (DLPFC). Path analyses identified a well-fitted model in which EN predicted grey matter density in DLPFC, which in turn predicted the disorganization score. CONCLUSION: Our findings suggest that EN during childhood could have an impact on psychopathology in schizophrenia, which would be mediated by developmental effects on brain regions such as the DLPFC.

La esquizofrenia atenuada revisitada: la pérdida de la evidencia natural / The attenuated schizophrenia revisited: loss of the natural evidence

Blankenburg applied Husserl's phenomenolgy to patients with hebephrenic schizophrenia which no longer have a sense for what is sociable suitable. These patients lose a sense for things that are evident in every day common sense. Blankenburg debates with Jaspers and Binswanger about the role of intuition and phenomenological method in hebephrenia. He returns to a Husserlian approach of genetic phenomenology to uncover the loss of natural evidence in the formation of attenuated schizophrenia. Phenomenological philosophy can help clarify the concepts at the heart of schizophrenia and thus has practical relevance. Philosophical thinking and a more patient-centered approach to psychiatry should be integrated into the research of psychiatrists.

Blankenburg aplicó la fenomenología de Husserl en pacientes aquejados de esquizofrenia hebefrénica que ya no poseen un sentido para lo que es socialmente adecuado. Estos pacientes pierden el sentido para las cosas que son evidentes para el sentido común cotidiano. Blankenburg debate con Jaspers y Binswanger acerca del papel de la intuición y el método fenomenológico en la hebefrenia. Él retorna a la fenomenología genética para develar la pérdida de la evidencia natural en la formación de la esquizofrenia atenuada. La filosofía fenomenológica puede ayudar a clarificar los conceptos en el corazón de la esquizofrenia y así conseguir relevancia práctica. El pensar filosófico y un acercamiento en psiquiatría más centrado en el paciente se debe integrar a la investigación de los psiquiatras.

Psychiatric Autoimmunity: N-Methyl-D-Aspartate Receptor IgG and Beyond.

BACKGROUND: Descriptions of psychiatric autoimmunity beyond N-methyl-D-aspartate (NMDA) receptor encephalitis are sparse. OBJECTIVE: To report the autoimmune psychiatric spectrum currently recognized in Mayo Clinic practice. METHODS: Medical record review, testing of stored serum and cerebrospinal fluid for IgGs reactive with synaptic receptors and ion channels, neuronal nuclear and cytoplasmic antigens (including glutamic acid decarboxylase 65-kDa isoform) and case-control comparison were conducted. Patients were categorized into group 1, all adult psychiatric inpatients tested for neural autoantibodies (2002-2011; n = 213), and group 2, all Mayo NMDA receptor IgG-positive patients (2009-2013; n = 13); healthy control subjects were also included (n = 173). RESULTS: In group 1, at least 1 serum autoantibody (but not NMDA receptor IgG) was detected in 36 of 213 psychiatric inpatients. In total, 12 patients were determined retrospectively to have high-likelihood autoimmune encephalitic diagnoses. The most commonly detected autoantibody specificities were voltage-gated potassium channel ([Kv1] VGKC) complex (6) and calcium channel (P/Q type or N type; 5). Symptoms seen were as follows: depressive (8), anxious (7), psychotic (7), disorganized (5), suicidal (3), manic (1) and catatonic (1). In group 2, among 13 NMDA receptor IgG-positive patients, 12 had encephalitis; their psychiatric symptoms were as follows: depressive (9), catatonic (9), disorganized (8), anxious (8), psychotic (7), manic (6), and suicidal (3). Catatonic symptoms were more common in the 12 NMDA receptor IgG-positive patients than in the 12 group 1 patients with high likelihood of encephalitis (p = 0.002). Antibody positivities were usually low positive in value among healthy controls (12 of 16 vs 3 of 12 group 1 encephalitis cases, p = 0.025). NMDA receptor IgG was not detected in any healthy control subject. CONCLUSIONS: A spectrum of psychiatric autoimmunity beyond NMDA-R IgG may be under-recognized. Diagnosis is facilitated by combining results of comprehensive psychiatric, laboratory, radiologic, and electrophysiologic evaluations.

Maintenance electroconvulsive therapy for a neuroleptic-intolerant patient with disorganized schizophrenia.

Owing to unresolved questions concerning the efficacy and safety of electroconvulsive therapy (ECT) in the treatment of schizophrenia, and widespread negative attitudes toward ECT, maintenance ECT (mECT) is generally considered only as a last resort. Nevertheless, in some clinical situations, the advantages of mECT may outweigh the risks and associated concerns. We report the case of a patient suffering from disorganized schizophrenia who had life-threatening hematological side effects to treatment with antipsychotic agents. Long-term mECT was administered and the patient achieved remission with no notable side effects. He was able to maintain a peaceful daily routine and improved functioning. Considering the lack of controlled trials in this area, this case and other similar cases reported in the literature add support to a possible benefit of mECT in disorganized schizophrenia, particularly when pharmacotherapy is insufficient or contraindicated.