Kraepelinian subtype and deficit syndrome in chronic schizophrenia

The present study examined the clinical overlap between the Kraepelinian and deficit subtypes of schizophrenia. A total of 103 patients with schizophrenia were divided into four groups on the basis of the presence or absence of the two classifications, and the demographic and clinical characteristics of the groups were statistically compared. There was a significant overlap of Kraepelinian and deficit status, but nevertheless the retention of both classifications appears to be justified.     

Kraepelinian and non-Kraepelinian schizophrenia subgroup differences in cerebral metabolic rate

We studied two subtypes of schizophrenia. the Kraepelinian subtype (n = 10) characterized by an unremitting and severe course and the non-Kraepelinian subtype (n = 17) characterized by a remitting course and some periods of self-care. Patients were assessed with positron emission tomography (PET) with 18F-deoxyglucose (FDG) and high-resolution magnetic resonance imaging (MRI). A group of 32 age- and sex-matched normal volunteers served as comparison subjects. During the FDG tracer uptake period, patients performed a serial verbal learning task. MR images were segmented into gray, white and cerebrospinal fluid regions, and warped to average normal coordinates. PET images were coregistered to the MR images and similarly warpedfor analysis. Kraepelinian subtype patients were characterized by lower metabolic rates in the temporal lobe and cingulategyrus. and lower fronto/occipital ratios than non-Kraepelinian subtype patients. Exploratory statistical probability mapping alsorevealed lower metabolic rates in the right striatum in Kraepelinian versus non-Kraepelinian patients. These differences couldnot be attributed to differences in age, symptom severity, task performance during FDG uptake, or severity of involuntary movements. Factor analysis of the cortical surface identified significantly lower temporal lobe metabolic rates in Kraepelinian patients than non-Kraepelinian patients. A combined frontal/temporal deficit or greater cortical change may be associated with poorer longitudinal course.     

A pilot neuropsychological study of Kraepelinian and non-Kraepelinian schizophrenia

OBJECTIVE: This is the first study to report a direct comparison of neuropsychological performance in Kraepelinian vs. non-Kraepelinian schizophrenia (SZ). METHODS: 17 Kraepelinian and 19 non-Kraepelinian subjects were assessed on a neuropsychological battery including the Purdue Pegboard, Schwartz' Reaction Time task, the Modified Card Sorting Test, the Wechsler's Associate Learning Test and the Digit Span. RESULTS: Kraepelinian schizophrenia was characterized by more impaired performance on the Purdue Pegboard and the Card Sorting test. These differences remained significant when introducing, as covariates, the type of neuroleptic used, the use of anticholinergic medication, age and gender. Differences on the Reaction Time, the Associate Learning and the Digit Span tasks did not reach statistical significance. CONCLUSIONS: These results suggest that Kraepelinian schizophrenia is characterized by impaired performance on fine motor dexterity and executive functioning. These results further add to the evidence for the validity of the distinction between Kraepelinian and non-Kraepelinian schizophrenia as a strategy to better understand the factors influencing severity and/or outcome in schizophrenia.     

Depression in schizophrenia

Depressive syndromes that occur during the course of schizophrenia are not clearly understood but have important implications for the treatment of the schizophrenic patient. In this review of the literature on depression secondary to schizophrenia, the author notes that lack of tested diagnostic criteria has led to a misunderstanding of its relatively high frequency and its association with poor outcome features such as impaired psychosocial functioning, schizophrenic relapse, and suicide. Differential diagnosis, including ruling out akinetic depression, is essential, he believes, partly because the concept of schizophrenic depression as postpsychotic is not supported by evidence. Clinical management must address such increased risk factors as relapse and suicide, but evidence indicates that secondary depression in schizophrenia does not respond to antidepressant medication.     

The Kraepelinian tradition

Emil Kraepelin (1856-1926) was an influential figure in the history of psychiatry as a clinical science. This paper, after briefly presenting his biography, discusses the conceptual foundations of his concept of mental illness and follows this line of thought through to late 20th-century “Neo-Kraepelinianism,” including recent criticism, particularly of the nosological dichotomy of endogenous psychoses. Throughout his professional life, Kraepelin put emphasis on establishing psychiatry as a clinical science with a strong empirical background. He preferred pragmatic attitudes and arguments, thus underestimating the philosophical presuppositions of his work. As for nosology, his central hypothesis is the existence and scientific accessibility of “natural disease entities” (“natürliche Krankheitseinheiten”) in psychiatry. Notwithstanding contemporary criticism that he commented upon, this concept stayed at the very center of Kraepelin''s thinking, and therefore profoundly shaped his clinical nosology.     

Multidiagnostic evaluation of prolactin response to haloperidol challenge in schizophrenia: maximal blunting in Kraepelinian patients.

We have previously reported that prolactin (PRL) responses to haloperidol 0.5 mg IV were blunted in subjects characterized by several diagnostic systems of schizophrenia compared to controls (Keks et al 1990). However, an attempt to find a diagnostic system most different from controls was unsuccessful due to inherent difficulties in the statistical analysis of multidiagnostic data. In this paper we present new methodologies. A test for differences in dependent correlations demonstrated that most of the variance in stimulated PRL was accounted for by Kraepelinian, and least by Schneiderian and M. Bleulerian, schizophrenias (p < 0.001). The main symptomatic difference between nonKraepelinian and Kraepelinian patients was the presence of association disturbance and feelings of passivity. Patients with both symptoms had a lower stimulated PRL than controls. Further findings and possible implications are discussed.     

Depression Scale (DEPS) in schizophrenia

OBJECTIVE: To explore the applicability of the Depression Scale (DEPS), a screening instrument for detecting depression in primary health care, in schizophrenia. METHOD: The DEPS was compared with the Calgary Depression Scale (CDS) among 63 patients with schizophrenia. RESULTS: Using the CDS as a gold standard, the positive and negative predictive values of the DEPS for the diagnosis of depression were 41% and 97%, respectively. The correlation between the total CDS scores and the total DEPS scores was 0.73. CONCLUSION: The DEPS appears to be useful for screening depression among schizophrenic patients, but the positive diagnosis must be confirmed with a clinical interview.     

Depression in the long-term course of schizophrenia

Abstract Depressive symptoms are quantitatively and qualitatively among the most important characteristics of schizophrenia. The following contribution reports on the prevalence of depression in 107 patients of the ABC schizophrenia study over 12 years after first hospital admission, looks into a preponderance of depression at certain stages of the illness and the predictive value of depressive symptoms for course and outcome. All but one of the 107 patients experienced one to 10 episodes of depressed mood between index assessment and long-term follow-up. In any month of the observation period about 30–35% of the patients presented at least one symptom of the depressive core syndrome (depressive mood, loss of pleasure, loss of interests, loss of self-confidence, feelings of guilt, suicidal thoughts/suicide attempt). Depressive symptoms are particularly frequent during a psychotic episode at a rate of approximately 50%. There were moderate but statistically significant correlations between the amount of depressive symptoms during a psychotic episode and the frequency of relapses, defined by hospital admissions as well as the total length of inpatient treatment. Depression occurring in the interval was not associated with an increased need for inpatient treatment.     

Depression and cognitive deficits in geriatric schizophrenia

Objective

Past reports have found patients with comorbid depression and schizophrenia spectrum disorders exhibit greater deficits in memory and attention compared to schizophrenia spectrum disorder patients without depressive symptoms. However, in contrast to younger schizophrenia patients, the few past studies using cognitive screens to examine the relationship between depression and cognition in inpatient geriatric schizophrenia have found that depressive symptomatology was associated with relatively enhanced cognitive performance. In the current study we examined the relationship between depressive symptoms and cognitive deficits in geriatric schizophrenia spectrum disorder patients (n = 71; mean age = 63.7) on an acute psychiatric inpatient service.

Method

Patients completed a battery of cognitive tests assessing memory, attention and global cognition. Symptom severity was assessed via the PANSS and Calgary Depression Scale for Schizophrenia.

Results

Results revealed that geriatric patients' depression severity predicted enhancement of their attentional and verbal memory performance. Patients' global cognitive functioning and adaptive functioning were not associated with their depression severity.

Conclusion

Contrary to patterns typically seen in younger patients and non-patient groups, increasing depression severity is associated with enhancement of memory and attention in geriatric schizophrenia spectrum disorder patients. Also, diverging from younger samples, depression severity was unassociated with patients adaptive and global cognitive functioning.     

The Kraepelinian Dichotomy Viewed by Neuroimaging

The Kraepelinian dichotomy between schizophrenia (SZ) and bipolar disorder (BD) is being challenged by recent epidemiological and biological studies. We performed a comparative review of neuroimaging features in both conditions at several scales: whole-brain and regional volumes, brain activity, connectivity, and networks. Structural volumetric neuroimaging studies suggest a common pattern of volume decreases, but networks studies reveal a clearer distinction between BD and SZ with an altered connectivity generalized to all brain networks in SZ and restricted to limbic, paralimbic, and interhemispheric networks in BD.Key words: schizophrenia, bipolar disorder, Kraepelinian dichotomy, connectivity, neuroimaging     

Depression in schizophrenia: Current guidelines to treatment

Depressive symptoms and syndromes in schizophrenia are common but heterogeneous with respect to etiology, presentation, course, and treatment. Based on a comprehensive differential diagnosis that identifies ten clinical subgroups, the authors review relevant treatment studies and offer current treatment guidelines. The clinical recommendations focus on addressing underlying problems such as medication side effects and substance abuse, attempting to identify and treat medication-responsive syndromes, and preventing suicide. The categories and treatments presented here are expected to evolve as researchers continue to elucidate clinically meaningful syndromes and to develop specific treatments. Nevertheless, current knowledge suggests that many schizophrenics with depression and depression-like symptoms can be treated effectively.     

Depression dexamethasone nonsuppression and negative symptoms in schizophrenia

This study compared three measures of depression in schizophrenia and their correlation with the Dexamethasone Suppression Test (DST). The degree of overlap of these three measures with negative symptoms was also examined. The Hamilton Depression Rating Scale (HDRS), the depressive syndrome score of the Present State Examination (PSE), and the Scale for the Assessment of Negative Symptoms (SANS) were administered to 50 acutely ill, hospitalized schizophrenics. Patients were diagnosed using DSM-III criteria for schizophrenia. DSM-III criteria were also used to assess the presence of a major depressive episode. Results were that DST nonsuppression was significantly associated with the presence of a major depressive episode, but not with depressive rating scale scores or with negative symptoms. It is concluded that the DST may be of value in differentiating a depressive syndrome from a negative symptom syndrome in schizophrenia.     

The Kraepelinian dichotomy in terms of suicidal behaviour

The Kraepelinian dichotomy sees schizophrenia and bipolar disorder as two distinctly separate diseases each with its own pathogenesis and disease process. This study looks at the difference between patients with schizophrenia and bipolar disorder in terms of suicidal behaviour. Both schizophrenia and bipolar disorder have been identified as significant risk factors for suicide, while bipolar and major depressive disorder appear to be the greatest diagnostic indicators. This study also aims to look at any differences in suicidal behaviour between the two major classes of bipolar disorder (bipolar I and bipolar II) to possibly determine how distinct these two conditions are in this respect. As expected, this study found that patients with a diagnosis of bipolar disorder were significantly more likely (OR=4.79) to have a history of suicidal behaviour than patients with a diagnosis of schizophrenia. Neither bipolar I nor bipolar II patients were significantly more likely to have a history of suicidal behaviour. However, this study yielded a weak association between bipolar II patients and suicidal behaviour (OR=1.83) compared to bipolar I patients, which may have been more significant under different circumstances such as a greater sample size.     

The Kraepelinian dichotomy in terms of employment outcomes

We assess the effectiveness of return to employment, and hence social inclusion in patients with chronic schizophrenia and bipolar affective disorder within a British community mental health team.     

Use of Kraepelinian concepts in international computer diagnosis

In the 1960s, diagnosis in the UK followed Kraepelinian principles whereas that in the United States of America was influenced by Freudian concepts. The US Department of Health became alarmed at the large proportion of patients with schizophrenia entering State Mental Hospitals compared to the proportion entering the Area Mental Hospitals in England and Wales. Social theories of mental illness were in vogue and some thought that mental illness reflected the state of society. The US UK Study employing Kraepelinian principles of diagnosis found no essential difference in the mental hospital statistics of the two countries. Later, the study examined the similar problems of discrepancy between depression in the UK and dementia in the US with similar results this time confirmed by outcome. Over the succeeding years psychiatric diagnosis in the USA was to undergo a radical overhaul and fall into line with that of most of the rest of the world, and even move ahead with the publication of DSM III. In order to allow larger population studies to be examined the computer-assisted program AGECAT was developed again, along Kraepelinian principles. Cases of mental illness were defined according to purpose rather than as substantive objects in their own right. Using these methods it has been possible to assess the prevalence and incidence of mental disorders in older people in Europe and Asia and question the fundamental pathology of Alzheimer’s (Kraepelin’s pupil and colleague) Disease using population sampled brain tissue. Derivatives of AGECAT, for younger subjects adapted for clinical use aim to carry Kraepelinian principles into the treatment of populations at present unserved by psychiatric care.