Helmut Beckmann

Early Childhood Catatonia

The special form of schizophrenia found in early childhood has not been described in previous editions of this book. The main reason for this is that in the course of my psychiatric activities I seldom saw severe cases of mental retardation from which I could obtain useful information. I did become acquainted with early childhood schizophrenia and as mentioned above have described it, but I thought that such cases were very rare, and fundamentally could not at all be separated from later childhood schizophrenia. I did not know that among the supposed severely retarded children there might be many early childhood schizophrenics. As I came across such cases I started to recognize their independent significance after the thought had occurred to me that I should be looking in departments of child psychiatry among mentally retarded patients for patients with schizophrenia, not of early childhood cases but throughout childhood. I thought I would discover at the most one or two cases, in fact I saw very few schizophrenics who had become ill in later childhood; in reality I found many cases which had begun in early childhood and thus got to know the great significance of this clinical picture.

The Cycloid Psychoses

Psychotic syndromes of cycloid psychoses have been described by both WIRNICKE (1900) and KLEIST (1928). My concept of these disorders is somewhat different. For WERNICKE anxiety-happiness psychosis appears in two separate forms: anxiety psychosis on the one hand, and “expansive autopsychosis with autochthonous ideas ”on the other. WERNICKE developed the concept of “motility psychosis”, but he did not separate periodic catatonia from it. Later Kleist and Fūnfgeld (1936) described the differential diagnosis from schizophrenic disorders. Wernicke denoted the two poles of the disorder as “cyclic motility psychosis”. Confusion psychosis appeared to him as either “periodic maniacal autopsychosis ”or “agitated confusion”, inhibited confusion psychosis as “intrapsychic akinesia”. In the latter KLEIST spoke of “confused stupor”. The concept “confusion ”comes from MEYNERT. KLEIST included anxiety psychosis and happiness psychosis which he considered as “inspiration psychosis ”in his “paranoid marginal psychoses”, while he grouped motility psychosis and confusion psychosis with “cycloid marginal psychoses”

Clinical Pictures of Phasic Psychoses (without Cycloid Psychoses)

Until very recently nearly all psychiatrists were united in the opinion that manic and depressive disease pictures were all part of manic-depressive illness. It was the work of ANGST (1966) and PERRIS (1966) that helped spread my theory that unipolar and bipolar diseases were separable. I carried out my first investigations together with NEELE. KLEIST (1943), with whom we were working, shared my opinion. Previously, KLEIST had claimed that there was no independent manic-depressive illness, but rather only melancholia and mania with a certain reciprocal affinity. Thus he had already postulated the independence of the unipolar forms, but had gone too far by denying the independent existence of manic-depressive illness. The genetic difference between the unipolar and bipolar forms was seen in that the manic-depressive form had a significantly higher rate of psychoses among relatives than did unipolar forms. WINOKUR (1969) and others followed in this line of thinking. However the two disease forms also have different clinical pictures. The bipolar form displays a considerably more colorful appearance; it varies not only between the two poles, but in each phase offers different pictures. The unipolar forms, of which there are several (ANGST, PERRIS, WINOKUR do not treat this) return, in a periodic course, with the same symptomatology.

The Systematic Schizophrenias

The sharpness of their symptomatology differentiates the systematic schizophrenias from the unsystematic forms. Whereas in periodic catatonia, cataphasia, and affective paraphrenia we always drew attention to their sympto-matological polymorphism, precluding strict delineation, in the systematic forms we find sharply circumscribed pictures. Apparently this parallels what we have observed in the phasic psychoses where alongside the polymorphic forms we had pure forms with their firm symptomatology. Probably the parallel exists because both the pure phasic forms and the systematic schizophrenias involve specific functional areas, the limits of which produce the sharp borders of the psychoses. No further relationship should be assumed because the phasic psychoses may be remediable while the systematic schizophrenias show permanent defects. The functional areas affected by the two sets of disorders are not only different here and there but are in fact of a very different nature. Pure depressions, euphorias, and manic-depressive illness are disorders of the emotions in close association with the vegetative nervous system, whereas the schizophrenias clearly imply disorders of higher thought and of willpower. Even the affective flattening of the hebephrenias does not suggest a disorder of the basic emotional system; rather it is at a higher level that affectivily is changed, while the more bodily types of feelings and instinctual drives are maintained. As I have discussed precisely elsewhere (Leonhard 1970a), in the schizophrenias the highest, and at the same time the phylogenetically youngest human functions of the psyche are involved.

The Unsystematic Schizophrenias

Systematic and unsystematic schizophrenias have essentially nothing to do with each other. The common name is justifiahle only in terms of tradition, because since Kraepelin and Bleuler all endogenous psychoses leading to defect have been grouped as schizophrenias. The deep parallels of the unsystematic schizophrenias are much closer to the cycloid psychoses than to the systematic schizophrenias. This relationship is above all emphasized by the fact that each of the cycloid forms corresponds to one of an unsystematic schizophrenia. There are relationships between anxiety-happiness psychosis and affective paraphrenia, between motility psychosis and periodic catatonia, and between confusion psychosis and cataphasia. The differential diagnosis is often difficult. On the other hand there rarely is a problem in differentiating between a systematic and an unsystematic schizophrenia. Not only are the symptomatic pictures completely different, but their course as well is quite different. The systematic forms display an insidious onset with a gradually progressive course, while the unsystematic forms may go into remission or may even be clearly periodic. Periodic catatonia may produce as many attacks as manic-depressive illness. Bipolarity, too, is characteristic of the unsystematic schizophrenias.

Karl Leonhard’s Life (1904–1988)

Karl Leonhard was born on 21 March 1904 in Edelsfeld, Bavaria, son of a Protestant minister. He went to high school (Humanistisches Gymnasium) in Weiden, Oberpfalz, and then studied medicine in Erlangen, Berlin and Munich. After having finished his studies he became assistant physician for a short period of time at the Psychiatric Clinic of the University of Erlangen, under Specht. Then in 1931 he moved to the Psychiatric Hospital (Heil- und Pflegeanstalt) Gabersee, Upper Bavaria. A year later he was appointed senior physician and commenced pioneer investigations of the clinical pictures of defect-schizophrenics (”Defektschizophrene Krankheitsbilder”), attracting the attention of Karl Kleist. In 1936 Kleist called him to Frankfurt/ Main as senior physician, where a year later he was given an academic appointment in recognition of his work.

Etiology of Endogenous Psychoses

In spite of very intensive efforts made for decades with regard to elucidating the genesis of endogenous psychoses, very little is known. It is known that hereditary disposition plays a role; it is assumed that psychosocial factors are significant. But it is not known what the nature of the hereditary disposition is, nor which kinds of psychosocial factors are involved. This gross deficiency is, in my opinion, derived from the fact that since Kraepeiin’s days etiological investigations have been carried out on only one schizophrenia and only one manic-depressive disorder (in the broad sense of the term). The separation at last of manic-depressive illness from monopolar depression has held good; whereas the “schizoaffective psychoses” now frequently mentioned have not led to any useful separation, as these include schizophrenic as well as phasic, especially cycloid psychoses. I have had the opportunity in recent years to spend much time conducting investigations and research, with the result that much more is now known than previously.

Age of Onset, Sex Incidence, Course

Having consolidated my method of differentiated diagnosis, I have undertaken, with the help of my co-workers, a review of the earlier statistical findings. There were no fundamental changes but it was necessary to make some important modifications. To a certain extent, this statistical section has been shortened since, in the mean time, Angst (1966), and, independently, Perrjs (1966) and later Winokur et al. (196P9), have published extensive statistics on unipolar and bipolar phasic psychoses, confirming the different natures of these disorders. These authors have, like myself, found that both the number and duration of the phases as well as the extent among relatives were different, although they did not base their reasoning on these differences. Perris demonstrated that, in the relatives of unipolar patients, primarily unipolar forms reappeared and that the relatives of bipolar patients suffered primarily from bipolar forms. Angst examined sex incidence among psychoses in the relatives and found very significant differences. The number of women greatly exceeded that of men among the affected relatives of the unipolar group, but this was not the case for the bipolar group. Frau von Trostorff (1968) confirmed Angst’s results, even though she did not find the differences quite as great.

The Question of Endogenous Mixed Psychosis

For many years the psychiatric literature has contained articles on mixed psychoses. It was assumed that schizophrenia as an entity was not infrequently combined with manic-depressive illness; the symptom picture and course of the disorder showed a mixture of both components. This was supposed to have been an explanation for the so-called “atypical” psychoses. Attempts were made to show that such patients had inherited one psychosis from one parent and the other psychosis from the other parent. But investigation did not show this to be true. The concept of mixed psychosis has gradually-receded and in more recent times no longer plays an essential role. But the concept of “schizoaffective” psychoses has taken over and has led to attempts to distinguish these from schizophrenia and the phasic psychoses. In my own investigations the question of mixed psychoses played no important part as I was able to include most of the so-called atypical psychoses among the cycloid psychoses. For a period of time I assumed that, if different endogenous psychoses came together on a hereditary basis, one would exclude the other. But I had to correct this assumption. I can confirm that two psychoses in one person occur extremely rarely. The rarity depends, as I now assume, on the fact that different endogenous psychoses have different causes which generally are not found together in a single person at the same time. It has to be kept in mind that each separate form occurs very rarely, taking into account that the incidence of all schizophrenic disorders in the average population is less than 1%. Such rare disorders could hardly co-occur with another equally rare. I had to abandon the notion of mutual exclusion of different endogenous psychoses from the fact that such combinations may actually be observed. I did see a few in the course of many years.