Karl Leonhard

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Karl Leonhard (born March 21, 1904 in Edelsfeld , Bavaria; † April 23, 1988 in Berlin ) was a German psychiatrist who was in the tradition of Carl Wernicke and Karl Kleist and continued their work. He developed a differentiated classification of endogenous psychoses according to nosological criteria.

In addition, Leonhard has written a diverse work on various psychological , psychotherapeutic and bio- psychological topics and left a classification of human expression that arranges facial expressions , gestures and phones according to content criteria.

Leonhard was a humanist and campaigned all his life for a dignified treatment of mentally ill people. During the time of the Third Reich , Leonhard, like Karl Kleist , was one of those psychiatrists who no longer made dangerous diagnoses in order to protect patients from being murdered as part of Action T4 . In particular, the schizophrenic diagnoses were no longer made or documented. In the post-war period he moved to the GDR , where he worked scientifically until his death.

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Karl Leonhard was born on March 21, 1904 in Edelsfeld near Sulzbach / Opf. as the sixth of eleven children of the pastor Oskar Leonhard and his wife Julie, b. Maier.

From 1910 to 1914 he attended elementary school in Wilchenreuth near Weiden / Upper Palatinate, then from 1914 to 1923 the humanistic grammar school in Weiden / Upper Palatinate. He studied medicine from 1923 to 1928 in Erlangen, Berlin and Munich. In 1929 he received his doctorate as Dr. med in Erlangen. From 1929 to 1931 he worked as a doctor at the Psychiatric and Mental Hospital of the University of Erlangen, then from 1931 to 1935 at the sanatorium and nursing home in Gabersee (Wasserburg am Inn). This was followed by a position at the Erlangen sanatorium in 1935 . In 1931 he also married.

In 1936 he was called by Karl Kleist to be a senior physician at the city's mental hospital and the University of Frankfurt am Main . In 1937 Karl Kleist completed his habilitation for a work done in Gabersee / Upper Bavaria; this was followed by a lectureship in psychiatry and neurology at the University of Frankfurt .

In 1946 he was appointed adjunct professor at the University of Frankfurt. In 1950 Leonhard was not appointed Kleist's successor in favor of Jürg Zutt, who represented a different doctrine ( anthropology , analysis of existence , social psychiatry ). In 1955 he was relocated to the GDR and was professor of psychiatry and neurology at the Medical Academy in Erfurt .

In 1957 he was appointed full professor of psychiatry and neurology at the Humboldt University in Berlin . He became the medical director of the Charité mental hospital .

In 1964, Zutt retired and was offered a professorship from Frankfurt, which he could not accept because the GDR authorities did not allow him to leave the country, although he had contractually negotiated the promise when he moved in 1955, a possible appointment to a West German university to be allowed to follow. He stayed at the Charité . In 1965 he was elected a member of the Leopoldina . In addition to dealing with endogenous psychoses, Leonhard devoted himself to psychotherapy. In 1958 he founded one of the first psychotherapy departments in Germany at a university clinic, where he practiced an independent form of psychotherapy, the "individual therapy of the neuroses."

May 31, 1969 he retired in Berlin.

On August 1, 1969, it was reappointed to ord. Professor without teaching or administrative duties; as compensation for the breach of contract in 1964. From 1969, Leonhard moved to another office at the Charité, continued to have a secretary and a research assistant, did scientific work on a daily basis and was primarily involved in research. Between 1928 and 1988 he wrote 21 monographs and 263 publications.

Until shortly before his death on April 23, 1988 in Berlin, he worked at the Charité.

In 1984 he was awarded the Star of Friendship of Nations in silver.

Classification of endogenous psychoses

Unitarian vs etiological approach

According to Leonhard, at the beginning of the 19th century, two opposing traditions emerged in the discussion of the nosology of endogenous psychoses , which are still facing each other in their further developed forms.

1. On the one hand, the concept of a unified psychosis (unitarian conception), which was developed by Wilhelm Griesinger and Heinrich Neumann , among others . This tradition is based on a few causes of psychotic illnesses that are largely determinative beyond nosology and various symptoms. The various manifestations of psychosis and schizophrenia are understood hereafter only as individual forms, which are essentially based on uniform causes . This unitarian view therefore only sets up a few diagnostic units (large groups) and was initially confirmed by modern pharmacopsychiatry , since most drugs can be used successfully in many "psychoses" regardless of the differential diagnosis . The ICD and DSM classifications, which are dominant today, are essentially unitarian, but also contain prognosis-oriented criteria (such as those set out by Kraepelin ) and symptomatologically oriented criteria (as used by Eugen Bleuler and Kurt Schneider ).
2. This is countered by the “etiological concept” by Carl Wernicke and Karl Kleist , from which Leonhard has developed the most differentiated division of endogenous psychoses to date. This tradition assumes that there must be numerous different causes of schizophrenia based on detailed clinical observations . The term "schizophrenia" can therefore generally only be a rough collective term which in reality designates a group of diseases to be separated from one another, which are only superficially similar. An essential support of this point of view is the meticulously worked out observation by Leonhard that previously distinctly described individual symptoms never mix with one another in a specific patient , but only combine. They always remain individual symptoms that can only occur in one patient at a time. According to this point of view, a patient may be suffering from different subtypes of psychoses at the same time.

Today, Emil Kraepelin's work (dichotomy of endogenous psychoses) is often seen as mediating between the two conceptions, but it could not make any contribution to clarifying the causation (etiology) of endogenous psychoses.

The Unitarian view in psychiatry can be compared with an “overall view ” that arises from the lack of neuronal processes largely beyond our knowledge. Only a few forms of disease are distinguished and treated more globally with drugs or psychotherapy. The Unitarian and the aetiological point of view oppose one another.

In favor of the Unitarian view, the fact that psychotropic drugs are generally proving to be very effective today and can help many patients, even if the pathological changes behind them in individual cases are not understood. A causal therapy for schizophrenic or psychotic illnesses is not possible today and there are a large number of psychiatric forms that cannot be treated adequately, but typically progressive and systematically deteriorate. The psychotropic drugs can unfavorable course often dampen and delay, but the appearance of new episodes not prevent it. According to this point of view, the psychotropic drugs available today are comparable to a first aid service that is often too unspecific and that has to be continued in the absence of specific, better treatment methods. In the classes established by Leonhard, they have little or no effect on the specific causes postulated by him, but unknown.

Meaning of the Leonhard classification

Leonhard was only aware of a wide range of different, but distinct symptoms, although the biochemical causes remained largely unknown to him throughout his life. Its classification divides psychiatric forms exclusively according to nosological and etiological criteria and draws on detailed observations of the symptoms. The causes of psychiatric illnesses, however, are more complex than the consequences of surgical accidents and are not based on a single noxious agent , but rather on a sequence of influences and processes that in turn influence each other.

According to this point of view, the patients have a long and complicated path of suffering behind them, with which the disease and the symptoms (in interaction with the social environment) develop over a long period of time. Precise clinical observation is based on a very thorough medical history and careful observation of individual symptoms. According to Leonhard, global psychiatric disease patterns can be broken down into specific class features. Then statements about prognosis and indicated forms of therapy are possible.

Leonhard's classification represents a decomposition of psychotic forms . The criteria used are symptoms and a. used in the following areas:

• History and course of the disease (intensive)
• Affectivity of the patient
• Thinking skills / thought disorders
• Expressive behavior / expressive sickness

Today, Leonhard's classification is particularly interesting for research, as the nosological classes can be related to biological-psychiatric findings and can be used as independent factors in research projects . The more common classifications contained in the ICD-10 and DSM-5 are particularly suitable for everyday psychiatric use and for correspondence with health insurers and medical service providers, who have gained significant importance in modern clinical operations. Both perspectives complement each other.

Classes of endogenous psychoses

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The following lists the classes and types of endogenous psychoses as originally developed by Karl Leonhard. The terms come from a historical view of psychosis and include severe clinical pictures that do not fall within the range of the classic neurosis term.

Leonhard differentiated between phasic and cycloid psychoses . Phasic disease get lost whenever the symptoms after the occurrence of a nudge subsides residuals leaves and later with a further impetus to continue again. These can be phased progressively, for example. Cycloid psychoses, on the other hand, are those that are not followed by any residual symptoms after an often severe acute phase of illness . The patient recovers and can restore himself to the experiences associated with his own illness.

Unlike in modern classifications, Leonhard's term schizophrenia is not a collective diagnosis, but only a sub-form of endogenous psychosis. The schizophrenia can therefore proceed systematically and unsystematically, whereby he assumed in later editions of his work that the two are only symptomatically similar, but have two different causal complexes due to the course forms. Leonhard subdivided two further classes into catatonias and schizophrenias in early childhood, which in his opinion must have other causes.

Phasic psychoses

• Manic-Depressive Disease (now Bipolar Disorder )
• purely melancholic and manic symptoms
  • Pure melancholy
  • Pure mania
• purely depressive and euphoric symptoms
  • Pure depression
    • Haunted depression
    • Hypochondriac depression
    • Self-agonizing depression
    • Suspicious depression
    • Unresponsive depression
  • Pure euphoria
    • Unproductive euphoria
    • Hypochondriac euphoria
    • Enthusiastic euphoria
    • Confabulatory euphoria
    • Unresponsive euphoria

Cycloid psychoses

• severe acute phases of the disease after which no residual symptoms appear

• Fear-happiness psychosis (primarily affect disturbed)
• Excited-inhibited confusion psychosis (primarily mental performance impaired)
• Hyperkinetic-akinetic motility psychosis (primarily motor disorders )

Unsystematic schizophrenia

In the course of the disease, mostly moderate residual conditions develop .

• Affective paraphrenia (primarily affect is disturbed)
• Cataphasia (schizophasia) (primarily the mental performance is disturbed)
• Periodic catatonia (primarily motor skills are disturbed)

Systematic schizophrenia

An often creeping course can be observed here; mostly severe residual conditions develop .

Simple systematic schizophrenia

Hebephrenia

In the case of hebephrenia , above all affective performances are disturbed to the effect that either "indirect" feelings or the will formation resulting therefrom is considerably impaired. Indirect feelings are feelings about future or past events, while "immediate" feelings are triggered by present experiences. The immediate feelings are little affected in the Hebephrenic patients. So the sick can indeed about z. B. enjoy a game that he is playing, but - if the indirect feelings are disturbed - hardly affected emotionally by positive or negative events to be expected in the future.

Because of this lack of emotion, the will formation is disrupted - or in some forms indirect feelings occur, but the will formation per se does not work. In both cases, the sick live into the day, do not make any decisions about the future and are therefore usually not in a position to take adequate care of themselves. Hebephrenia usually starts early, often in childhood or adolescence. A negative symptoms is in the foreground. Positive symptoms can be mild or moderate, but they are rarely in the foreground and are mostly only temporary. The following sub-forms are distinguished:

• Foolish Hebephrenia: Typical is a smiling facial expression, which can be provoked in particular by turning to the sick person. Often the behavior of those affected appears adolescent, they often tend to - sometimes even malicious - pranks or foolishness. There is also a considerable lack of drive. The patient's thinking is largely correct in terms of form and content, but they make little effort to provide high-quality answers, often answer prematurely and then make little effort to improve.
• Quirky Hebephrenia: In the beginning, obsessive-compulsive symptoms often appear in the sick, later often manners (idiosyncrasies). In terms of mood, those affected seem persistently a little disgruntled. They complain of complaints, mostly of a physical nature, which has a hypochondriac character. Typically, these complaints are presented unchanged in the longitudinal course, i.e. even after several years. In the course of the process there is an increasing flattening of affect. Thinking is less restricted than with foolish hebephrenia. In the absence of positive symptoms, those actually suffering from psychosis run a certain risk of being misdiagnosed or misdiagnosed as obsessive-compulsive patients.
• Flat hebephrenia: More clearly than with other forms of hebephrenia, states of depression occur periodically. These are often accompanied by hallucinations, sometimes also with relationship ideas. After having gone through a state of depression, the sick can distance themselves from the hallucinatory symptoms. Outside of the moody states, the sick are usually carefree satisfied. In this form of hebephrenia, the affects flatten very clearly, but those affected can still have largely meaningful conversation. As with all forms of hebephrenia, the ability to plan ahead is impaired and the sufferers stand out because they have little or no plans for the future.
• Autistic Hebephrenia

Paraphrenia

Here the mental performance is primarily disturbed (predominantly paranoid forms of schizophrenia). The following sub-forms are distinguished:

• Hypochondriac paraphrenia
• Phonemic Paraphrenia
• Incoherent paraphrenia
• Fantastic paraphrenia: There are hallucinations of an optical, acoustic, olfactory and gustatory nature as well as physical sensations - all of which are sometimes very bizarre - as well as delusions. Typical of the fantastic paraphrenia are descriptions of the sick about scenic hallucinations that affect different sensory areas. There are also fantastic ideas, some of which are completely absurd (e.g. that it is quite normal for the dead to come back to life). Grotesque misrecognition of persons is also characteristic (the sick often recognize great, significant personalities in their vicinity); Any size ideas that arise also have an absurd character. Sick people are emotionally aroused by their world of experience (e.g. by their scenic hallucinations, which are often cruel), and if not of long duration or high intensity. Thinking can be (moderately) erratic, erratic, but there is no severe incoherence in thinking. Linguistic mistakes (e.g. someone feels "worn out") and grammatical errors occur frequently.
• Confabulatory paraphrenia
• Expansive paraphrenia

Catatonia

• In catatonia, the motor function is primarily disturbed, and it is distorted or severely restricted in different ways. The following sub-forms are distinguished:
  • Parakinetic catatonia
  • Manned catatonia: motor skills become impoverished with increasing rigidity. Involuntary movement sequences decrease, voluntary movements become inharmonious and wooden. This also makes speaking less modulated. The changes in body movements or motor skills have a certain similarity to the hypokinetic-rigid symptoms of Parkinson's disease . It occurred mannerisms on, so meaningless movements that repeat themselves (eg. As body rotation when passing through doors, putting away the cutlery between bites). These can be differentiated diagnostically from compulsive actions , since the latter aim to reduce feelings of unpleasantness (fear) or to prevent them from arising, which is not the case with manners. In the context of mannered catatonia, movements that do not take place regularly are rarely carried out in the later stages of the disease - as if they had been forgotten. Practicing movements / everyday activities is therefore very important therapeutically.
  • In advanced stages of the disease, the sick can care less and less because they lack the necessary movement repertoire; the radius of action can be considerably restricted. There are also negligence manners (refusal to eat, always standing in the same place, mutism). Affectivity is only slightly impaired in the disease; affect flattens out over time. Thinking is only slightly impaired, and in the course of the disease there are probably only mild intellectual losses.
  • Proskinetic catatonia
  • Negativistic catatonia
  • Catatonia ready to speak
  • Speech-induced catatonia

Combined systematic schizophrenia

• These psychoses are considered to be rare forms with a very poor prognosis. This classifies when one person has several simple systematic forms at the same time, e.g. B. the combination of an incoherent with a phonemic paraphrenia, which is then referred to as incoherent-phonemic paraphrenia. The existence of very rare 3-way combinations is also described by Karl Leonhard. He stated that he only observed combinations within a group (simple catatonias, hebephrenias or paraphrenias), but no combinations between these groups. The diagnosis of a combined form is particularly difficult in view of the many forms and also the possible emergence of completely new symptoms or because opposing symptoms of the individual simple form can mutually cancel each other out. The following sub-forms are distinguished:
  • Combined systematic catatonia
  • Combined systematic hebephrenia
  • Combined systematic paraphrenias
  • Combined systematic schizophrenia

• early childhood catatonia
• early childhood schizophrenia

Publications (selection)

Karl Leonhard worked primarily as a psychiatrist . But he left a very diverse scientific work that also relates to areas of psychology.

• Distribution of endogenous psychoses and their differentiated etiology. 8th edition. Georg Thieme Verlag, Stuttgart / New York 2003, ISBN 3-13-128508-7 . (German, English, Italian, Spanish, Japanese)
• Differentiated diagnosis of endogenous psychoses, abnormal personality structures and neurotic developments. 4th edition. Ullstein Medical, Verlag Gesundheit, Berlin 1991, ISBN 3-333-00616-2 .
• The human expression in facial expressions, gestures and phonics. 3. Edition. Würzburg 1997, ISBN 3-00-002040-3 .
• V. Leonhard (Ed.): My person and my tasks in life. Volume 4 of the series of publications by the Wernicke-Kleist-Leonhard Society. Verlag Frankenschwelle H.-J. Sailer, Hildburghausen 1995, ISBN 3-86180-050-0 .
• Biological psychology. 6th edition. S. Hirzel Verlag, Stuttgart 1993, ISBN 3-7776-0500-X . (German Hungarian)
• Great personalities in their mental illnesses. 2nd Edition. Ullstein Mosby, Berlin 1992, ISBN 3-86126-014-X .
• Child neuroses and child personalities. 4th edition. Berlin 1991, ISBN 3-333-00617-0 .
• Individual therapy of the neuroses. 3. Edition. Thieme, Leipzig 1981, ISBN 3-437-10730-5 .

(Publisher's cover of the first edition 1948)

• Accented personalities. 2nd Edition. Berlin 1976, ISBN 3-437-10447-0 . (German, Romanian, Russian)
• Biopsychology of endogenous psychoses. Hirzel, Leipzig 1970.
• Normal and abnormal personalities. Verlag Volk und Gesundheit, Berlin 1964.
• Instincts and Primal Instincts in Human Sexuality. At the same time a contribution to the history of the development of human instincts. Enke, Stuttgart 1964.
• Individual therapy and prophylaxis of hysterical, anankastic and sensohypochondriac neuroses. G. Fischer, Jena 1959.
• Basics of Neurology. Enke, Stuttgart 1951.
• Laws and meaning of dreaming. At the same time a criticism of the dream interpretation and an insight into the workings of the subconscious. 2nd Edition. Stuttgart 1951. (German, Spanish)
• Expression language of the soul: representation of facial expressions, gestures and phonics of the human being. Haug Verlag, Berlin 1949.
• Basics of psychiatry. Enke, Stuttgart 1948.
• The laws of normal dreaming. Thieme, Leipzig 1939.
• Defect schizophrenic clinical pictures: their division into two clinically and hereditary biologically different groups and into sub-forms of the character of systemic diseases. Leipzig 1936.

literature

• Helmut Beckmann, Klaus-Jürgen Neumärker, Mario Horst Lanczik, Thomas Ban, Bertalan Pethö (ed.): Karl Leonhard - The scientific work in magazines and compilations. Volume 1–3 of the series of publications by the Wernicke-Kleist-Leonhard Society. Berlin 1992, ISBN 3-333-00689-8 .
• Ernst Franzek, Gabor S. Ungvari (eds.) Recent Advances in Leonhardian Nosology I. Würzburg 1997, ISBN 3-00-001749-6
• Bertalan Pethö: Classification, course and residual dimension of endogenous psychoses. Budapest, ISBN 3-89559-259-5 .
• Ernst Franzek, Helmut Beckmann: Psychoses of the schizophrenic spectrum in twins. Springer Verlag, Berlin 1998, ISBN 3-540-64786-4 .

Web links

• Literature by and about Karl Leonhard in the catalog of the German National Library
• Search for "Karl Leonhard" in the SPK digital portal of the Prussian Cultural Heritage Foundation
• International Wernicke-Kleist-Leonhard Society
• Remembering Professor Dr. med. Karl Leonhard (PDF file; 137 kB) Article in the Hessisches Ärzteblatt, issue 3/2004
• PsychiatrieOnline.org
• Julian Schwarz: Biography of Karl Leonhard In: Biographical Archive of Psychiatry (BIAPSY) .

Individual evidence

1. ↑ Neues Deutschland , March 6, 1984, p. 2
2. ↑ The section "Leonhard's classes of endogenous psychoses" is essentially based on: Karl Leonhard: Division of endogenous psychoses and their differentiated etiology. 8th edition. Georg Thieme Verlag, Stuttgart / New York 2003. ISBN 978-3-13-128508-9 . (See also limited preview on GoogleBooks )