Schizophrenia A Provisional Diagnostic Convention

Gisela Gross1 and Gerd Huber1

Due to the lack of pathognomonic somatic findings, every diagnostic concept of schizophrenia can only be a provisional convention. If, for example, first rank symptoms (FRS) are present and a brain disease is excluded, ''we speak in all modesty of schizophrenia'' [1]. Here, to assert ''right'' or ''wrong'' diagnoses is not justified. We can only state that the disorder may be called schizophrenia according to the criteria, for example, of Kraepelin, Bleuler, Schneider, Leonhard, ICD-10 or DSM-IV. The crucial question is not whether

1Department of Psychiatry, University of Bonn, D-53105 Bonn (Venusberg), Germany the state is schizophrenia, but ''does it fit with what I am accustomed to call schizophrenia'' [1]? The frequency of FRS depends on the duration of observation. In the long courses, FRS occur in 79% of cases, in the first 6 months after onset in 52% [2]. The most frequent among FRS and second rank symptoms (SRS) are delusional ideas (86%) and auditory hallucinations (75%), followed by schizophrenic ego-experiences (51%), delusional perception (42%), and bodily (39%), visual (33%), olfactory (13%) and gustatory (11%) hallucinations [2]. In 21% of cases the diagnosis has to rely merely on SRS and expression symptoms [2]. Of the latter, formal thought disorders have—because of their infrequency (e.g. blocking 22%) and little specificity—less diagnostic value, except incoherence (54%). Catatonic initial syndromes (4.7%) occur more rarely than in the past [2]. In the whole course, catatonic hyper- and hypophenomena are found in 55% of cases. Also disturbances of affect and initiative and the negative symptoms (NS) affective flattening, avolition, alogia and anhedonia, occurring in a variety of disorders, are of little diagnostic value, even if blunted and inappropriate affect are differentiated from ''feeling of unfeelingness'', present mainly in endogenous depressions [1], but also in pure residues of schizophrenia [2,3]. ''Anhedonia'' is a much too all-inclusive term. Cognitive deficits in neuropsy-chological tests must be distinguished from cognitive thought disorders, a frequent (75%) basic symptom (BS) in basic stages, partly correlated with cognitive deficits [2, 4]. The BS's diminution of emotional responsiveness, drive, initiative and thought intentionality [3] are the subjective pendants of the NS affective flattening, avolition and alogia.

As to the ''prodromal or residual symptoms'' (PRS), essential empirical data of the BS research [5, 6] are neglected in DSM-IV and ICD-10. As the pure residues [7], prodromes and outpost syndromes [8], preceding the first psychotic episode 3.3 or 10 years respectively [2], are determined by BS, which are, unlike NS and the PRS of DSM, experiential and not behavioural in kind, typically only recognizable by the self-reports of the patients, who have no lack of insight and are able to develop coping strategies [3, 5, 6]. The BS are rateable by the Bonn Scale for the Assessment of BS [3] and can be differentiated in non-characteristic level-1 and rather characteristic level-2-BS; out of distinct level-2 cognitive thought, perception and action BS, distinct FRS develop, as has been shown in the first prospective early recognition study in schizophrenia [9,10], the transition rows study [11] and earlier inquiries [5,6,12]. Early treatment including the prodromes improves the long-term prognosis [2,13]. BS, positive symptoms (PS) and NS must be differentiated and develop in this chronological sequence: first BS, followed only years later by PS and finally NS [3,5, 9,10].

The data regarding the outcome depend on the diagnostic concept. The results of the European long-term studies, using Schneiderian and/or Bleule-rian criteria, represent — according to Zubin — a revolution in the knowledge of schizophrenia [13]. Besides 22% with complete remissions, 40% of the cases remit with mainly slight ''pure residues'', determined by BS as the prodromal stages; 56% are fully employed, even if only 38% at the premorbid level [2]. The long-term studies have also shown the huge heterogeneity of outcome, with social remission ranging in the 12 course types from 100% to 2% [2,14]. The prognostically favourable factors of the Bonn study, for example, acute onset, depressive syndromes, psychoreactive precipitation, normal primary personality, are identical to criteria used to classify schizoaffective or cycloid psychoses [6,14]. As to the subtypes, the cenaesthetic schizophrenia [15,16] became by its very long (7 years in average) prodromes a prototype for the early recognition research. This type is still today less known, as is the case with the ''pure defect'' (7), corresponding partly to Crow's type II, that is, correlated with ventricular enlargement, but determined by BS and not by NS [2, 5, 17]. We found in schizophrenics an enlargement of lateral and, preferentially, third ventricles, associated with the ''pure defect'' and partly progressing parallel to the psychopathological deficit [7, 12, 17]. The first episode of schizophrenia begins before age 20 in females in 18% of cases and in males in 32% of cases, while late-onset schizophrenia is seen in females in 22.4% of cases and in males in 10.6% of cases [2].

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