Schizophrenia concepts
Under the keyword clinical schizophrenia concepts , facts and theories are summarized that deal with the descriptions and classifications of schizophrenia as a disease created by doctors . Schizophrenia is a worldwide disease and occurs over the entire lifetime of a person with a risk in the order of 1%. Most patients fall ill before the age of 30. A third of those affected experience a lifelong disappearance of symptoms, but a further third develop a severe chronic disability as a result of the disease. The characteristic features of the disease include the so-called first-rate symptoms according to Kurt Schneider (see below). The cause of the disease is unknown. The onset of the disease is usually preceded by a prodromal phase lasting several years: This is the period of non-specific symptoms before the onset of the disease.
This article presents the most important clinically defined concepts of schizophrenia since Emil Kraepelin's first clear definition of schizophrenia in 1893 in chronological order.
The foundation
The basis of our understanding of schizophrenia today is Emil Kraepelin's distinction between “ dementia praecox ” and “manic depressive insanity”. With this distinction Kraepelin took the fundamental step to differentiate schizophrenia from affective disorders . His next systematic step was to divide schizophrenia into subtypes, specifically the three types:
The clinical concepts and their founders
Based on this thought by Kraepelin, the assumption of Wilhelm Griesinger (1817–1868, doctor, full professor of medicine in Kiel and Tübingen, founder of the modern psychiatric clinics), mental illnesses are brain diseases, and based on Karl Jaspers ' (1883–1969, psychiatrist and philosopher, full professor of philosophy in Heidelberg 1921–1937, forced retirement, and 1948–1961 in Basel: founder of modern psychopathology) methodological considerations on general psychopathology, the following concepts for the classification of schizophrenia were developed in the 20th century. In psychiatry they are associated with the names of their "inventors":
- Eugen Bleuler 1857-1939. Professor of Psychiatry in Zurich. Director of Burghölzli (Psychiatric Clinic in Zurich) until 1927: The group of schizophrenias.
- Kurt Schneider 1887–1967. Full professor of psychiatry in Heidelberg from 1946 to 1955. Head of the clinical department of the DFA from 1931: Concept of First-Line Symptoms, 1938.
- Klaus Conrad 1905–1961. Professor of neurology and psychiatry in Saarbrücken from 1948 to 1958 and Göttingen from 1958. Employee at the DFA from 1934: stages of madness.
- Gerd Huber . Professor emeritus for psychiatry in Bonn: basic disorder concept.
- Tim Crow . Professor Emeritus of Psychiatry at Oxford: Type I and Type II Schizophrenia.
- Nancy Coover Andreasen . Professor of Psychiatry at the University of Iowa, USA: Negative Symptoms.
- Peter Liddle . Professor of Psychiatry in Nottingham: Dimensional Approach.
- Joseph Zubin : Vulnerability-Stress-Coping Concept.
The situation today
The current understanding of schizophrenia is primarily characterized by three developments:
- Discovery of neuroleptics ,
- Catamnesis research and
- Psychiatry reform .
Due to a far-reaching criticism of the existing classification systems and organizational considerations (standardization of the nomenclature, formation of homogeneous patient populations for clinical and genetic studies, billing modalities), patients with mental illnesses according to the ICD-10 and DSM-5 catalogs are almost everywhere today diagnosed and the various forms of schizophrenia classified accordingly. This concept is presented in the article on the diagnosis of schizophrenia .
Emil Kraepelin and the "Dementia praecox"
The basis of Kraepelin's schizophrenia concepts is clinical-pragmatic progress research. Since a cross-sectional image, which shows snapshots of the condition of a mentally ill person, is subject to strong fluctuations over time, it seemed logical not to base a system on the highly variable aspects of the disease, but on progress observations from which one can assume greater reliability promised the assessment. Kraepelin's work is closely related to a critical examination of 19th century psychiatry. For his classification of mental illnesses and thus also of schizophrenia, Kraepelin received the work of Ewald Hecker on "Dementia hebephrenica" from 1871 and the studies of Karl Ludwig Kahlbaum (1828–1899, doctor, professor of medicine in Königsberg) on "Dementia paranoides" and to the "Dementia catatonica" or - as it was also called - the "tension madness" of 1874. He also took Jean-Pierre Falrets (1794–1870) observation that manic and depressive episodes were part of an illness in some patients. Following the example of Falret's unification of depression and mania to "folie circulaire", the circular insanity, Kraepelin unified the three forms of dementia paranoides, katatonica and hebephrenica according to Kahlbaum and Hecker to form dementia praecox.
The "natural units of disease"
Kraepelin also decided to give up the idea of unit psychosis based on Griesinger, in favor of a purely empirical approach: If the follow-up observations gave evidence of unit psychosis, one could keep the term, otherwise one would have to abandon it. Kraepelin's third fundamental consideration is to orientate oneself only on one's own experience and not on philosophical or neuroanatomical assumptions. This leads to the central assumption that mental illnesses are biologically based "natural units of illness ".
Kraepelin stuck to this concept of "natural disease units" throughout his life, although as a good clinician he increasingly saw the limits of the concept: Kraepelin recognized the personality of the patient, his life situation and the quality of his social relationships as factors that influence the course of the disease Disease can affect. He therefore called these factors " pathoplastic " (disease-forming).
Kraepelin initially distinguished three groups of diseases: delirium , states of exhaustion and the group of the "mad" and "mad". This subdivision can be compared quite casually with the triadic concept still valid today .
First phase: Differentiation from traditional concepts
Kraepelin's concept of schizophrenia can be divided into three phases in his teaching and theory formation: In the early period (1880–1890) Kraepelin did not use the term “dementia praecox”. Here he mainly criticizes the diagnostic systems of the 19th century. At this time Kraepelin was already describing a group of patients with psychoses who tended to become chronic.
Second phase: The "dementia praecox" and its subtypes
In the middle period (1891-1915) he first described the difference between cross-sectional and longitudinal findings. In 1893 he first mentioned the term “dementia praecox”. In addition to "catatonia" and "dementia paranoides", it is characterized by a poor prognosis. The poor prognosis was an argument for him to believe that the disease was physical. He describes the poor prognosis with the terms “psychological degeneration” or “dullness”. In 1899 Kraepelin first made the distinction between "dementia praecox" (schizophrenia) with a chronic course and poor prognosis on the one hand and "manic depressive insanity" (affective disorders) with a phased course and a good prognosis on the other.
Kraepelin distinguished between three forms of “dementia praecox”: the hebephrenic, catatonic and paranoid subtypes. In later publications he distinguished up to ten subtypes. Kraepelin believed that the "dementia praecox" was caused by an organic disease process, and that the disease may not be uniform. He ruled out the possibility of a cure.
Third phase: consolidation
In the late period from 1916 Kraepelin dealt with criticism of his concept, but made no further changes to his considerations.
Eugen Bleuler and the group of schizophrenias
Eugen Bleuler brought two weighty arguments into the discussion about the classification of schizophrenia. On the one hand, he carefully studied the symptoms of the disease and proposed a framework for classifying it that is still useful today. In addition, Bleuler proposed an alternative to Griesinger's concept of “unit psychosis” with the term “group of schizophrenias”.
Primary and Secondary Symptoms
Bleuler was a student of Freud and one of the first psychiatrists who tried to make the results of psychoanalysis useful for psychiatry. His lasting merit is based on this part of his scientific work. Bleuler found that the symptoms of his patients were very different and therefore no longer wanted to speak of a disease, but of a disease group. In addition, it was his aim to create the most comprehensive schizophrenia theory possible. Like Griesinger, he started from the idea of a somatic disease of the brain and assumed that this brain disorder leads directly to the so-called primary symptoms - above all, thought disorders and certain physical symptoms. The patient's active confrontation with these primary disorders leads to the so-called secondary symptoms of schizophrenia: delusions, hallucinations, affect disorders.
| Primary symptoms | Secondary symptoms |
|---|---|
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Basic and accessory symptoms
With this keyword Bleuler introduces his definition of the four capital A (affect, association, ambivalence, autism), which is still in use today and which he regarded as the most important basic symptoms. In schizophrenia, they should always occur when the disease is more advanced. According to Bleuler, the so-called accessory symptoms only occur occasionally and also occur in other diseases.
| Basic symptoms | Accessory symptoms |
|---|---|
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Kurt Schneider and the phenomenological approach
Kurt Schneider's science concept
The distinction between symptoms of the first and second rank goes back to the Heidelberg psychiatrist Kurt Schneider (1887–1967). Schneider viewed schizophrenia as an organically based disorder of the brain. However, Schneider explicitly saw this assumption, known as the “somatosis postulate”, as a model or “heuristic principle”. Because of this critical self-limitation, he viewed psychiatric diagnoses not simply as names for objectifiable "natural disease units" in the sense of Kraepelin, but as conceptual constructs that can be justified as well as possible. Schneider therefore suggested that in the case of psychiatric illnesses, instead of a differential diagnosis, we should speak of a differential typology. After all, in medicine one speaks of diagnoses in the narrower sense only if the etiology and pathogenesis of a disease are precisely known. However, this is known not to apply in the case of schizophrenia. With this pragmatic and at the same time cautious attitude, Schneider is considered a pioneer of so-called operationalized diagnostics, as it was implemented in the ICD-10 and DSM-IV catalogs.
First and second tier symptoms
What he calls first-rate symptoms allow the diagnosis of schizophrenia. In this sense, on the one hand, they are cardinal symptoms: the disease is defined by them. On the other hand, a list of diagnostic criteria for schizophrenia can be drawn up by examining first- and second-tier symptoms. With a certain combination of such findings, the diagnosis of the disease can be made.
| First-rate symptoms | Second rate symptoms |
|---|---|
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The triadic system of psychiatry
The so-called “triadic system” in psychiatry goes back to Kurt Schneider. Based on the so-called rule of layers by Karl Jaspers, it means the division of mental illnesses into three groups:
- Physically justifiable diseases, such as dementia;
- Endogenous psychoses and
- Variations of normal mental experience.
The triadic system is still in use for many reasons. It is a classification criterion for textbooks, it is found modified in the arrangement of the diseases in the ICD catalog, and it is found - slightly modified - in legal terminology in Germany, for example when examining the culpability of a suspected criminal.
Klaus Conrad: The stages of madness
In his classic study of the onset of schizophrenia, Klaus Conrad described five stages of madness.
The delusion begins with the so-called Trema , a kind of preparatory phase in which the person concerned is characterized by inner restlessness, fear and the feeling of “destruction of the structure of the situation”. In the second phase, the so-called. Apophenia , the delusion patients experienced an abnormal importance awareness. He can no longer change his judgments regarding the madness and develops the conviction that everything revolves around him ( anastrophe ). In the third phase of the madness, the apocalyptic , the madman experiences states of the greatest fear, sometimes intoxicatingly elevated mood, acute hallucinations and develops a disintegration of speech and thought. This acute phase can lead to a state of consolidation , the fourth phase. In it the patient turns from the expansive phase of his madness to the fifth phase, the residual state , which can most simply be described as a state of apathy.
This Conrad concept has been checked by Hambrecht. It turned out that the idea of logically successive stages of madness cannot be proven empirically. Only the trivial sequence “unspecific before specific symptoms” could be demonstrated.
Nancy Andreasen: Positive and Negative Symptoms
In modern schizophrenia research, negative symptoms are given a lot of attention. Nancy Andreasen introduced the "six A" as a rule of thumb:
The "six A" according to Andreasen
- Alogy : The impoverishment of speech leads, for example, to prolonged response latencies, the patients are taciturn.
- Affect flattening: The impoverishment of affects manifests itself in a reduced ability to “participate emotionally”.
- Apathy : This primarily refers to a lack of energy and interest, lack of drive and weak will ( abulia ).
- Anhedonia : means joylessness and listlessness.
- Attention Disorder: Patients find it difficult to concentrate, read a text, follow a conversation, etc.
- Antisociality: This describes the disruption of the patient's ability to communicate.
Negative symptoms are not easy to spot. They are not revealed so much through questioning the patient, but rather through observation, reconstruction of the social anamnesis and a detailed anamnesis from others . Numerous scales have been developed to assess the extent of negative symptoms.
Primary and secondary negative symptoms
In psychiatric research, a distinction is also made between primary and secondary negative symptoms. The primary negative symptoms, which are viewed as closely related to the disease, are primarily the flattening of affect and the impoverishment of speech. The group of secondary negative symptoms, which one sees as a consequence of the illness, consequence of coping strategies , side effects of medication, etc., includes above all: anhedonia, antisociality and apathy. The great importance of the negative symptoms for patients is that they often reduce the quality of life much more permanently than the positive symptoms.
Tim Crow: Acute and Chronic Schizophrenia
At the beginning of the 1980s, the English psychiatrist Tim J. Crow postulated the existence of two types of schizophrenia, which he called type I and type II schizophrenia. Type I should be characterized by acute occurrence, late onset of the disease and the predominance of positive symptoms. Type II, on the other hand, is characterized by the predominance of chronically present negative symptoms and cognitive losses with an early onset of the disease.
Gerd Huber: The basic disruption concept
The Bonn psychiatrist Gerd Huber did pioneering work in the following research areas of psychiatry:
- His studies of the asymmetry of the cerebral ventricles by means of pneumencephalography since the 1950s established biological psychiatry in Germany.
- His catamnesis studies revise Kraepelin's pessimistic assessment of the course of schizophrenia.
- With his studies on psychopathology, Huber is one of the founders of empirical psychopathological research in Germany.
Huber assumes that a number of negative symptoms are the basis of schizophrenic diseases. These symptoms should be close to the suspected somatic substrate of schizophrenia ( basic symptoms close to the substrate ). Research into these basic symptoms takes place today mainly in such a way that adolescents and children with mental disorders are examined in detail for these symptoms. On the one hand, psychoses are to be recorded as early as possible and, on the other hand, treatment criteria should be developed.
Liddle's dimensional approach
As part of studies on negative symptoms, Peter F. Liddle developed the concept of three dimensions of schizophrenia. For the purpose of classification, Liddle also described considerations for the neuroanatomical and neurophysiological characterization of the disorders.
| Lesion site: | left dorsal prefrontal cortex | medial temporal lobe | right ventral prefrontal cortex |
|---|---|---|---|
| Syndrome: | psychomotor impoverishment | Distortion of reality | Disorganization |
| Symptoms: |
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Lidle's classification describes less subtypes than dimensions of the disease, which can be more or less pronounced in each patient. The assignment of the dimensions to specific brain areas is not without controversy.
Integrative concepts
The older behavioristic and psychodynamic concepts have now been replaced by integrative models such as the vulnerability-stress-coping concept according to Joseph Zubin and the concept of affect-logical reference systems according to Luc Ciompi . The vulnerability-stress- coping model according to Zubin and Nuechterlein is an attractive etio - pathogenetic framework hypothesis.
This hypothesis states that the disease - given a given disposition ( vulnerability , i.e. vulnerability) - comes to an outbreak due to particular stress (stress) and the lack of adequate coping options. The willingness for the disease is seen organically, since the familial burden as the most important single factor for schizophrenia is to be seen as a genetic component. In the case of insufficient coping, stressors of any kind are supposed to lead to the failure of functional systems of the brain with the clinical consequence of psychotic symptoms.
The following are considered vulnerability factors:
- Disorders of the neurotransmitter functions ( dopamine hypothesis ),
- Functional consequences of changes in brain structure, especially in the limbic system,
- Disorders of attention and information processing,
- Schizotypal personality traits,
- Emotional and behavioral deficits in high-risk children.
The following are considered stressors:
- Critical and emotionally over-committed family climate,
- Overstimulating social environment,
- Stressful life events,
- Drug abuse.
The following are protective factors:
- Sensible coping strategies,
- Adequate problem-solving behavior in the family,
- Supportive social interventions,
- Antipsychotic medication.
Integrative schizophrenia concepts are primarily based on the needs of everyday clinical practice when it comes to the question of which treatment methods should be used. Since patients with schizophrenia not infrequently suffer severe social disabilities due to cognitive impairments caused by so-called negative symptoms, the question of an overall treatment plan that should take into account all areas of the patient's life always arises for therapists. This is where integrative disease concepts are used.
Other concepts of schizophrenia
In addition to the clinical concepts of schizophrenia, there are numerous other models for the classification and development of schizophrenia. This article has compared the areas of biological, psychodynamic and sociological disease models of schizophrenia with the clinical concepts of schizophrenia. This subdivision does not imply any valuation and is primarily due to the attempt at a meaningful restriction.
Biological concepts
The biologically defined disease concepts of schizophrenia mainly encompass four areas:
- The genetics of schizophrenia in the sense of a familial accumulation, the investigation of which goes back to the controversial geneticist Ernst Rüdin ,
- The elucidation of the mechanisms of antipsychotic drugs,
- The studies on morphological abnormalities of the brain of schizophrenic patients, based on the work of Gerd Huber, and
- Investigations that revolve around the issues of birth complications and infections.
The biological disease concepts of schizophrenia are dealt with under the lemma Neurobiological Schizophrenia Concepts.
Psychodynamic Concepts
The biological models for schizophrenia contrast with a long tradition of psychodynamic concepts, which in the 20th century can be traced back to the work of Sigmund Freud . In his study of the Schreber case, Freud proposed a psychodynamic model of madness. As a result, various researchers such as Gregory Bateson and Paul Watzlawick develop theories about the development of schizophrenia due to disturbed forms of communication and as a result of faulty parenting styles ( double bind , schizophrenic mother ).
Sociological Concepts
Strictly sociological theories that speak of a "myth of mental illness" as they were advocated by the American psychiatry critic Thomas Szasz , the English representatives of antipsychiatry Ronald D. Laing and David Cooper and the protagonists of Italian anti-institutional psychiatry such as Franco Basaglia play no longer plays a role in modern clinical research. However, their concepts continue to exist in a modified form in modern social psychiatry . Sociological concepts of schizophrenia are discussed in detail in the articles on antipsychiatry.
Summary
The modern clinical understanding of schizophrenia is strongly influenced by the schizophrenia concepts presented here. The differentiation of schizophrenic psychoses from affective disorders by Kraepelin, Bleuler's concept of the group of schizophrenias, the triadic system, the conception of the first-rate symptoms as characteristic features of schizophrenia, the great attention of modern psychiatric research to the negative symptoms and finally the concept of basic disorders as an early indicator of the development of schizophrenia are firmly rooted in today's clinical thinking in psychiatry. Far-reaching criticism of the systematisation requirements of the respective individual concepts has, however, led to attempts in clinical research today to refrain from any theoretical assumptions.
See also
- Neurobiological Schizophrenia Concepts
- Symptoms and diagnosis of schizophrenia
- Subtyping of schizophrenia
- Onset and early course of schizophrenia
- Late schizophrenia
- Course of schizophrenia
- Therapy for schizophrenia
literature
- Martin Bürgy: The Concept of Psychosis: Historical and Phenomenological Aspects . In: Schizophrenia Bulletin , 34 (6), 2008, pp. 1200-1210.
- Michael Musalek: The different origins of schizophrenia and their philosophical foundations . In: Fortschr Neurol Psychiat , 73 (special issue 1), 2005, pp. 16–24.
- Biological Psychiatry
Individual evidence
- ↑ Max Schmauß: Schizophrenia. Pathogenesis, Diagnosis and Therapy. Bremen 2002, ISBN 3-89599-659-9
- ^ JK Wing, JE Cooper, N. Sartorius: Measurement and Classification of Psychiatric Symptoms. Cambridge University Press, Cambridge 1974
- ↑ TO Jablensky et al .: Schizophrenia: Manifestations, incidence and course in different cultures. A World Health Organization ten-country study. In: Psychol. Med. (Monograph Suppl. 20). Cambridge University Press, 1992.
- ^ Mathias Berger: Mental Illnesses. Clinic and Therapy. Munich 2004, ISBN 3-437-22480-8
- ↑ W. Griesinger: The pathology and therapy of mental illnesses. A. Krabbe, Stuttgart 1845
- ^ E. Kraepelin: Psychiatry. 4th edition. Abel (Meixner), Leipzig 1893
- ^ Eugen Bleuler: Dementia praecox or group of schizophrenias. Deuticke, Leipzig / Vienna 1911.
- ↑ K. Schneider: Clinical Psychopathology. 14th edition. Thieme, Stuttgart / New York 1992
- ↑ Karl Jaspers : General Psychopathology. 8th edition. Springer, Berlin / Heidelberg / New York 1965
- ^ K. Conrad: The beginning schizophrenia. 6th edition. Thieme, Stuttgart / New York 1992
- ↑ Hambrecht, Martin and H. Häfner: “Trema, Apophänie, Apocalypse” - Can Conrad's phase model be empirically justified? In: Fortschr. Neurol. Psychiatr. , 61, 1993, pp. 418-423, PMID 8112705 .
- ^ NC Andreasen: The Diagnosis of Schizophrenia. In: Schizophrenia Bulletin , 13, 1987, pp. 9-22. PMID 3496659 .
- ^ NC Andreasen et al .: Positive and negative symptoms. In: SR Hirsch et al. (eds.): Schizophrenia , pp. 28-45. Blackwell Science, Oxford 1995
- ↑ Tim J. Crow: The molecular pathology of schizophrenia. More than one disease process. In: British medical Journal , 280, 1980, pp. 66-68, PMID 6101544 .
- ↑ Joachim Klosterkötter (Ed.): Early diagnosis and early treatment of mental disorders. Berlin 1998, ISBN 3-540-64440-7 .
- ↑ Martin Hambrecht et al .: Early detection and early intervention of schizophrenic disorders. In: Deutsches Ärzteblatt , vol. 99, issue 44, November 1, 2002, p. B 2491
- ^ PF Liddle: The symptoms of chronic schizophrenia: a re-examination of the positive-negative dichotomy. In: British Journal of Psychiatry , 151, 1987, pp. 145-151, PMID 3690102 .
