P. Berner

Psychopathological Concepts of Dysphoria

Dysphoric conditions are increasingly postulated as representing independent mood disorders. However, despite much effort at clarification, their psychopathological definitions remain unclear and variable. This paper reviews some examples of these divergent definitions, most of which are based on quality of mood, as well as responsiveness to external stimuli. The paper then introduces a strategy in possible solution of the above-mentioned definition problems. Setting out from restriction of the term dysphoria to conditions of a morose, tense and irritated mood, as suggested by Snaith and Taylor, we support the opinion that dysphoria should be accepted as a third possibility of mood swing, as a psychopathological disturbance which can be well distinguished from stable and unstable mixed states.

Delusional Theme, Sex and Age

In a retrospective study of 865 delusional syndromes, connections were investigated between delusional themes and the sex of patients, and the ages in which these themes extensively occurred. According to previous reports, the results of this investigation indicated that differences exist between the ages of manifestation regarding the themes of hypochondria, persecution, love and jealously. Furthermore, differences could be observed between males and females in relation to the frequency of choice of particular themes, as well as the age of occurrence. Based on psychological studies concerned with the contents dependence on motives we conclude that the age distribution of delusional themes corresponds to the main existential concerns in different life periods.

Temporal Stability of Diagnostic Criteria for Functional Psychoses

200 first admissions with functional psychoses were interviewed with PSE and rated simultaneously according to different diagnostic criteria (ICD-9, RDC, DSM-III, St. Louis, Taylor, Vienna Research Criteria). At follow-up 7 years later 186 patients could be traced and a course diagnosis was applied to each patient. Temporal stability of diagnostic criteria was calculated for ICD-9, RDC and DSM-III by stability coefficient and kappa values and was used as a criterion for validity. Schizophrenia and affective disorder display considerable stability over time, no matter whether one uses ICD-9, RDC or DSM-III. The data for schizoaffective disorder are less impressive, the stability coefficient is much higher for schizoaffective bipolar than for schizoaffective depressive patients.

Course and outcome of delusional psychoses.

The authors reinvestigated 84 out of a sample of 90 patients with delusional psychoses after an interval of 6-9 years. The results of the follow-up showed a pattern of episodic versus chronic course which compares to follow-up studies on classically diagnosed schizophrenias. The authors found evidence for their hypothesis concerning the nosological heterogeneity of this group of psychoses and propose a syndromatological classification apart from the delusional symptomatology itself. What they call background symptomatology was divided into axial syndromes. The authors feel that this results in subgroups that are more homogeneous for course and outcome than the usual classification systems.

First-Rank Symptoms and Bleuler's Basic Symptoms

By comparing six different operational diagnostic systems (International Classification of Diseases, Diagnostic and Statistical Manual; 3rd ed., Research Diagnostic Criteria, St. Louis criteria, Taylor criteria and Vienna Research Criteria), the data presented in this paper illustrate how attribution to various categories of functional psychoses varies according to the applied algorithms. Bleulers basic symptoms are obviously considered by all of the compared systems to be more significant for attribution to schizophrenia than first-rank symptoms.

Heterogeneity of Delusional Syndromes: Diagnostic Criteria and Course Prognosis

In addition to genetic findings and treatment response, the course prognosis is also meant to be a possible validating criterion for diagnosis and diagnostic systems. In our study we used the polydiagnostic approach (i.e. the simultaneous application of various criteria for diagnosing a given disorder to one and the same population) to test the ability of several diagnostic systems to create homogeneous groups regarding the course (episodic/chronic). We applied Schneiders FRS, ICD-9, DSM-III, Spitzers RDC and the Vienna Research Criteria to 90 patients with the diagnosis of delusional syndrome (aside from any nosological classification), who underwent 6-9 years of follow-up. At the index examination, schizophrenia was most frequently diagnosed with Schneiders FRS, which apparently encompasses a very heterogeneous group of patients regarding psychopathology and course. Diagnostic systems which allowed the diagnosis of affective disorders despite the presence of mood-incongruent delusional symptomatology (DSM-III, RDC, Vienna Criteria) or offered the diagnosis of schizoaffective disorder (DSM-III, RDC) succeeded in separating subgroups with an episodic course on a statistically significant level. In ICD-9 this significance appeared only after exclusion of the schizoaffective cases from the group of schizophrenias. Our data thus uphold the old rule of thumb that affective symptomatology apparently has a very high prognostic value regarding the course of the illness and is in this respect superior to productive symptomatology (such as delusions and hallucinations), still taken to be pathognomonic for schizophrenia by some of the diagnostic criteria under study. This aspect warrants further investigation and should be taken into account in the development and improvement of diagnostic manuals (e.g. ICD-10, DSM-IV).

Familienbilduntersuchungen an Patienten mit paranoiden Psychosen

Among the first-degree relatives of 77 patients with delusional functional psychoses the authors found 13 schizophrenics (3.10%), 8 manic-depressives (1.91 %) and 14 cases with atypical psychoses (3.34%), following ICD-9 criteria. These figures were compared with the figures in the literature on the genetics of paranoid schizophrenics and nonschizophrenic paranoids, regarding the different composition of the samples. Subdivision of the original 77 patients, using the concept of the axial syndromes, was able to form two homogeneous subgroups of first-degree relatives: one with a schizophrenia prevalence of 6.52% (uncorrected) and without any manic-depressive secondary cases (endogeno-morphic-schizophrenic axial syndrome) and another with a manic-depressive illness (MDI) prevalence of 6.58% (uncorrected) without any secondary cases with schizophrenia or atypical psychosis. The first-degree relatives of the patients with an ‘organomorphic’ axial syndrome (usually excluded in other studies) had an increased rate of manic-depressive secondary cases (3.57%, uncorrected) and the highest rate of atypical psychosis (7.14%) without any schizophrenics, according to the etiopathogenetic heterogeneity of this group. 37 of the 77 patients were not assignable to any of the axial syndromes. In the first-degree relatives of these patients – best comparable to Kendler’s criteria for ‘delusional disorder’ – an increased rate of schizophrenics and atypical psychoses was found (3.59 and 3.08%, uncorrected); the figures for MDI were within normal limits. Our results suggest that the axial syndromes are a useful diagnostic instrument in identifying – from the genetic standpoint – in part very homogeneous subgroups. This allows the conclusion that they are indicators for hypothetical basic disturbances.

Unter welchen Bedingungen lassen weitere Verlaufsforschungen noch neue Erkenntnisse über die endogenen Psychosen erwarten

Exhaustive follow-up studies of schizophrenia from Zurich, Bonn and Lausanne have produced strikingly similar results, despite considerable methodological differences. These ‘classical’ modes of diffe

Methodological Aspects of Follow-Up Studies on Psychotic Patients in a Polydiagnostic Perspective

Polydiagnostic follow-up studies should explore whether certain definitions of a given disorder permit better prediction of the illness course than others and whether this good predictive validity is related to specific etiopathogenetic conditions. In order to carry out such studies successfully they should be based on broadly defined samples and comprise provisions for additional validation such as genetic data, neuropsychological testing etc. After an assessment at baseline and at discharge from hospital, the follow-up assessments should comprise five steps: (1) Identification of successful and unsuccessful diagnostic systems; (2) identification of features determining successful attribution; (3) analysis of successful systems; (4) analysis of unsuccessful systems, and (5) analysis of cases which have changed diagnostic attribution. The conclusions drawn from these analyses are intended to refine classification in psychiatry.

Delusional Psychoses: Genetic Findings as a Critical Variable for the Validation of Diagnostic Criteria

77 patients with delusional psychoses, regardless of their nosological attribution (except severe organicity), and their first-degree relatives were diagnosed with the Research Diagnostic Criteria (RDC) and the Vienna Research Criteria (VRC). The diagnostic procedure was performed blindly in the relatives. Both criteria were sufficiently capable of identifying a schizophrenic and affective subgroup of patients characterized by the appearance of homotypical secondary cases. Apart from a small RDC schizoaffective group differing in genetic pattern, there exists another large group of nonschizophrenic, nonaffective delusional disorders lacking a genetic link to the above-mentioned diagnoses. In respect to the development of the diagnostic criteria, the results of this study call for the formulation of a narrow definition of schizophrenia (as in the VRC) which is based on thought disorder and affective blunting with the exception of so-called productive symptomatology (delusions, hallucinations); separate criteria for schizoaffective disorders (as in RDC), and a broad and nonrestrictive definition for nonschizophrenic delusional disorders.