Putative schizophrenia subtypes based on clinical features

Kraepelin's clinical forms of dementia praecox

Acknowledging the diversity of the clinical pictures subsumed under dementia praecox and the absence of pathognomonic symptoms, Kraepelin¹ articulated, 'for the sake of a more lucid presentation', nine different 'clinical forms' (Table 1). However, he emphasized that 'we everywhere meet the same fundamental disorders in the different forms of dementia praecox, in very varied conjunctions, even though the clinical picture may appear at first sight ever so divergent'. The 'fundamental disorders', holding together the disease entity, were cognitive deficit (a 'general decay of mental efficiency') and executive dysfunction ('loss of mastery over volitional action'), most clearly manifested in the residual, 'terminal states' of the illness. Kraepelin was reluctant to impute aetiological significance to the clinical variants he described, and regarded the issue of a unitary process versus multiple disease states within schizophrenia 'an open question'. The renewal of interest in Kraepelin's dementia praecox since the 1990's has led researchers to attempt delineating a 'Kraepelinian' subtype of schizophrenia, in terms of negative or disorganized symptoms, poor outcome, neuropsychological deficits, and risk factors.^{54, 55, 56} However, as indicated in Table 1, Kraepelin's original typology allowed for much greater heterogeneity in the clinical manifestations of dementia praecox than it is currently assumed.

Table 1 - Emil Kraepelin's 'clinical forms'1.

Full table

TABLE 1

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Subtyping schizophrenia: implications for genetic research

A Jablensky

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Table 1. Emil Kraepelin's 'clinical forms'¹

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	Dementia praecox simplex
	('Impoverishment and devastation of the whole psychic life which is accomplished quite imperceptibly')
	Hebephrenia
	(Insidious change of personality with shallow capricious affect, senseless, and incoherent behaviour, poverty of thought, occasional hallucinations, and fragmentary delusions, progressing to profound dementia)
	Depressive dementia praecox (simple and delusional form)
	(Initial state of depression followed by slowly progressive cognitive decline and avolition, with or without hypochondriacal or persecutory delusions)
	Circular dementia praecox
	(Prodromal depression followed by gradual onset of auditory hallucinations, delusions, marked fluctuations of mood, and aimless impulsivity)
	Agitated dementia praecox
	(Acute onset, perplexity, or exaltation, multimodal hallucinations, fantastic delusions)
	Periodic dementia praecox
	(Recurrent acute, brief episodes of confused excitement with remissions)
	Catatonia
	('Conjunction of peculiar excitement with catatonic stupor dominates the clinical picture' in this form, but catatonic phenomena frequently occur in otherwise wholly different presentations of dementia praecox)
	Paranoid dementia (mild and severe form)
	(The essential symptoms are delusions and hallucinations. The severe form results in a 'peculiar disintegration of psychic life', involving especially emotional and volitional disorders. The mild form is a very slowly evolving 'paranoid or hallucinatory weak-mindedness' which 'makes it possible for the patient for a long time still to live as an apparently healthy individual')
	Schizophasia (confusional speech dementia praecox)
	(Cases meeting the general description of dementia praecox but resulting in an end state of 'an unusually striking disorder of expression in speech, with relatively little impairment of the remaining psychic activities')

Bleuler's 'group of schizophrenias'

Having coined the term 'schizophrenia' to replace dementia praecox, Bleuler⁴⁵ stated that schizophrenia 'is not a disease in the strict sense, but appears to be a group of diseases.Therefore, we should speak of schizophrenias in the plural'. He acknowledged that the clinical subgroups of paranoid schizophrenia, catatonia, hebephrenia and simple schizophrenia – retained in the present DSM and ICD classifications – were not 'natural' nosological entities. What were then the multiple 'schizophrenias'? Bleuler argued that 'the disease schizophrenia must be a much broader concept than the overt psychosis of the same name'. Along with the 'latent' schizophrenias, which manifested mainly aberrant personality traits, he listed atypical depressive or manic states, Wernicke's motility psychoses, reactive psychoses, and other nonorganic, nonaffective psychotic disorders as belonging to the broad group of schizophrenias, suggesting that 'this is important for the studies of heredity', thus foreshadowing the notion of schizophrenia spectrum disorders.

Date: 2016-04-22; view: 1015