Schizophrenia, schizophrenic syndrome or what? The pros and cons of a term and concept under pressure with a look back to diabetes mellitus (original) (raw)

2018, Neurology, Psychiatry and Brain Research

Schizophrenia, schizophrenic syndrome or what? The pros and cons of a term and concept under pressure with a look back to diabetes mellitus Somewhat 100 year ago two founding fathers of modern psychiatry coined the terms "dementia praecox" (Emil Kraepelin) and "schizophrenia" (Eugen Bleuler) to describe a putative disease unit (Kraepelin) or a syndrome or a group of disease units (Bleuler). Today there are but few clinicians and scientists who still believe that the broad varieties of paranoid, hallucinatory, hebephrenic and catatonic syndromes yet labelled schizophrenia according to ICD-10 may indeed represent one disease unit. Kurt Schneider in the midst of the 20th century described his famous core symptoms (1st and 2nd rank symptoms) for a disease he "called" schizophreniathe phrase in parentheses apparently was chosen to stress his own sceptic attitude towards the diagnosis "schizophrenia". In spite of this, the term schizophrenia has survived into our days, but recent progress from neuropsychiatric research strongly revives previous skepticisms. The different arguments for an actual revision of the term and concept of "schizophrenia" were outlined in a book written by one of the editorial authors (Tebartz van Elst, 2017) and in an International Neuropsychiatric Symposium at the University of Freiburg, Germany, on 27th November 2017, titled "The beginning and end of schizophrenia: Does neuropsychiatry terminate the era of schizophrenia?" and the respective arguments were discussed in detail (https://www.neurex.org/events/events-to-come/item/317-the-beginning-and-end-of-schizophrenia-does-neuropsychiatryterminate-the-era-of-schizophrenia): The first session of the Freiburg symposium focused on secondary forms of schizophreniform syndromes. Michael Trimble from the Institute of Neurology, UCL-London, UK gave an introduction into the history of neuropsychiatric thinking about idiopathic and secondary forms of psychotic syndromes referring to his latest book "The Intentional Brain". Ludger Tebartz van Elst, University of Freiburg/Germany, presented the concept of para-epileptic pathomechanisms to explain subgroups of schizophreniform syndromes in the context of pathological EEG findings present in about 6% of patients with the diagnosis schizophrenia. Olivier Bonnot, from the University of Nantes/France, explained that schizophrenia-like syndromes can be the sequel of metabolic storage diseases like Niemann-Pick Type C disease. Angela Vincent, one of the world's leading scientists in the area of antibody-related limbic encephalitis from the University of Oxford/UK, presented the latest insights into immunological encephalitis as a possible cause of schizophreniform syndromes. The second session of the Freiburg symposium focused on primary variants of schizophreniform syndromes. James Walters from the University of Cardiff/UK gave an overview on the genetic findings, highlighting the relevance of many different common genetic variants with generally low effect sizes and other rare genetic variants, which may have large effect sizes to produce the schizophreniform phenotype. Jacques Foucher, University of Strasbourg/France, introduced the thinking of the Wernicke-Kleist-Leonhardt School to classify different entities of what they thought to be primary psychotic disease. Jim van Os, from Maastricht University/Netherlands, him being a member of the DSM-5 group for the definition of schizophreniaspectrum-disorders, presented his groundbreaking research on the prevalence of psychotic phenomena in otherwise healthy and well-functioning people supporting a dimensional concept of psychosis. Stephan Heckers, from Vanderbilt University in Tennessee/USA, another member of the DSM-5 group for the definition of schizophrenia, outlined his ideas of how psychiatry can proceed between the opposing poles of categorical thinking in disease entities and dimensional conceptualization of psychotic features as properties that can be regarded as an extreme end of a given feature in a human being. At the end of the Freiburg symposium a controversial debate took place on the core question as to whether new neuropsychiatric developments might terminate the era of schizophrenia. While most speakers agreed on the view that schizophrenia is unlikely to represent one disease entity, considerably differing opinions were formulated with respect to the question, whether or not the term and the concept of schizophrenia should be abolished. By chance, just one day later a similar controversial debate was fought in the internet by another high-ranking international faculty on the question "Is schizophrenia dead yet?" (http://www.schizophreniaforum.org/forums/webinar-schizophrenia-dead-yet). In Japan even a new term to replacing "schizophrenia" was formally established by the psychiatric society some years ago. This actual scientific discourse illustrates that "schizophrenia" is not a self-evident concept any more, instead is being heavily scrutinized from different perspectives. Following a recent neuropsychiatric categorical perspective, it clearly appears that "schizophrenia" should be better termed "schizophrenic syndrome", the syndrome driven by a variety of underlying causes and pathophysiological pathways. Such a modified term would nevertheless keep a core psychopathological aspects of the old term (by "schiz"). Similarly, the Kurt Schneider concept seemed to focus on the most characteristic so-called first and second rank symptoms, although these were recognized to typically present in parallel with uncharacteristic or negative symptoms. The high prevalence of uncharacteristic symptoms, nowadays usually termed negative symptoms, match widely with the concept of basic symptoms proposed by Gerd Huber and others. Interestingly, so-called unspecific symptoms have been earlier described in organic