[Hebephrenia - a viable psychopathological construct?] / Hebephrenie ­ ein brauchbares psychopathologisches Konstrukt?

Ewald Hecker was the first psychiatrist to describe the disease entity of hebephrenia in some detail, focusing mainly on disturbances of affect. Later Emil Kraepelin and Eugen Bleuler saw hebephrenia as a subtype of dementia praecox or schizophrenia. Willy Mayer-Gross and Karl Leonhard characterized hebephrenia with highly differentiated psychopathological descriptions, whereas this construct only played a minor role in the works of Klaus Conrad and Kurt Schneider. The International Classification of Diseases (ICD-10) lists hebephrenia as a subtype of schizophrenia but in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) no subtypes of schizophrenia are mentioned and the concept of hebephrenia is thus lost. Hebephrenia can be seen as an ideal type describing a psychopathological course pattern. This construct can be useful to conceptualize a group of disorders of affect which otherwise escape description, especially since these psychopathological alterations of affect are difficult to operationalize. To have a viable concept of these disorders is relevant for the prognosis and therapy planning. If the concept of hebephrenia is abolished, important psychopathological knowledge might be lost for future generations of psychiatrists.

Are there valid subtypes of schizophrenia? A grade of membership analysis.

BACKGROUND/AIMS: Cluster analysis has had limited success in establishing whether there are subtypes of schizophrenia. Grade of membership (GoM) analysis is a multivariate statistical technique which has advantages when, as in schizophrenia, individuals conforming to pure types are uncommon and mixed forms are frequent. METHODS: GoM analysis was applied to 118 chronic schizophrenic patients. The patients were of all clinical subtypes, including 13 with simple schizophrenia. Both current and 'lifetime' symptoms were assessed, and two different rating systems were used. RESULTS: Specifying 3 pure types resulted in robust findings across analyses. One pure type corresponded to paranoid schizophrenia, one to simple schizophrenia and the third combined elements of hebephrenic and catatonic schizophrenia. Specifying 4 pure types split the original 3 pure types in ways which were not clinically intuitive. CONCLUSION: GoM analysis divides schizophrenia into subtypes along conventional lines, with the proviso that hebephrenic and catatonic schizophrenic patients are not separable, at least in the chronic stage of the illness.

[Autistic hebephrenia: concepts and findings]. / Die autistische Hebephrenie - Konzept und Befunde

The concept of hebephrenia according to Kleist and Leonhard describes distinct clinical entities with a chronically progressive course leading to residual syndroms with a clear cut symptom constellation which is stable over time. The main symptom is a specific kind of pathological affectivity resulting in a lack of profound future- orientated tension. In six case-reports we illustrate the characteristical clinical picture of the autistic hebephrenia, one of the four subforms of hebephrenic psychoses according to Leonhard. The characteristical clinical syndrom consists of an affective blunting, autistic withdrawal, unfathomable facial expression, unhappy mood and periods of moodiness with aggressive excitement. The concept of hebephrenia according to Kleist and Leonhard presents a promising heuristic attempt for biological-etiological research. In ICD-10 and DSM-IV the usual concept of hebephrenia is a rather vaguely defined nosological category with a polymorphous non-specific symptomatology.

The structure of psychosis: latent class analysis of probands from the Roscommon Family Study.

BACKGROUND: The nosologic structure of psychotic illness, still influenced as much by historical as empirical perspectives, remains controversial. METHODS: Latent class analysis was applied to detailed symptomatic and outcome assessments of probands (n=343) with broadly defined schizophrenia and affective illness ascertained from a population-based psychiatric registry in Roscommon County, Ireland. First-degree relatives (n=942) were assessed by personal interview and/or review of hospital record. RESULTS: Six classes were found, all of which bore substantial resemblance to current or historical nosologic constructs. In order of decreasing frequency, they were (1) classic schizophrenia, (2) major depression, (3) schizophreniform disorder, (4) bipolar-schizomania, (5) schizodepression, and (6) hebephrenia. These classes differed on many historical and clinical variables not used in the latent class analysis. Compared with relatives of controls, significantly increased rates of major depression were seen in relatives of depressed and schizodepressed probands. Significantly increased rates of bipolar illness were restricted to relatives of bipolar-schizomanic probands. The risks for schizophrenia and schizophrenia spectrum disorders were significantly increased in relatives of all proband classes except major depression. This increase was moderate for bipolar-schizomanic probands, substantial for schizophrenic, schizophreniform, and schizodepressed probands, and marked for hebephrenic probands. CONCLUSIONS: These results suggest a relatively complex typology of psychotic syndromes consistent neither with a unitary model nor with a Kraepelinian dichotomy. The familial vulnerability to psychosis extends across several syndromes, being most pronounced in those with schizophrenialike symptoms. The familial vulnerability to depressive and manic affective illness is somewhat more specific.

Symptom structure in schizophrenia: two-, three- or four-factor models?

Beside the syndromic dichotomy (negative-positive), other symptomatic dimensions have been described in schizophrenia. A question of interest is, therefore, to know which symptom structures can be individualized to characterize schizophrenia. Using confirmatory factor analysis in 135 patients, a two-factor model (negative-positive), a three-factor model (negative-positive-disorganization) and a four-factor model (negative-positive-disorganization-relational) were primarily identified with SANS (Scale for the Assessment of Negative Symptoms) and SAPS (Scale for the Assessment of Positive Symptoms). In contrast, no models could be identified with PANSS (Positive and Negative Syndrome Scale). The results confirm the relevance of other syndrome dimensions, beside the negative and positive ones and suggest that SANS-SAPS was more useful than PANSS in identifying an adequate dimensional factor structure of schizophrenic symptoms.

Factor structure of symptoms in functional psychoses.

Global ratings from the Scale for the Assessment of Positive Symptoms and Scale for the Assessment of Negative Symptoms were subjected to principal-component analysis (PCA) in 80 schizophrenia patients, 76 patients with schizophreniform disorder, 80 patients with schizoaffective and mood disorders, and 78 patients with delusional, brief reactive, and atypical psychoses. The resulting factors were correlated with depressive, manic, and catatonic syndromes, and subjected to a multivariate analysis of variance across DSM-III-R diagnoses. PCAs revealed that psychosis, disorganization, and negative factors were also present in each of the nonschizophrenic groups. The disorganization factor tended to be related to the manic syndrome, and the negative factor to depressive and catatonic syndromes. Overall, the three factors had little diagnostic relevance in functional psychoses, although the negative factor was relatively more characteristic of schizophrenia. The data suggest that positive, negative, and disorganization factors are not specific to schizophrenia; this is consistent with a dimensional view of psychopathology in functional psychoses.

Factor analysis of schizophrenic symptoms using the OPCRIT checklist.

Factor analysis was performed on OPCRIT checklist psychotic symptoms rated on 102 patients with DSM-III-R schizophrenia. An initial three-factor solution produced positive, negative, and disorganisation factors. However, application of the scree test suggested five substantive factors, with the positive factor dividing into three factors characterised, respectively, by paranoid symptoms, first rank delusions and first rank hallucinations.

Patterns of positive and negative symptoms in first episode schizophrenia.

BACKGROUND: The aim is to examine, in first episodes of schizophrenia, the appropriateness of the simple two-dimensional model of schizophrenia ('negative' and 'positive' dimensions) and more complex variants. METHOD: All patients with a first episode of schizophrenia who, over a two-year period, made contact with any of the public mental health services of the autonomous region of Cantabria in northern Spain were investigated. The psychiatric evaluation included, among other instruments, the Present State Examination (PSE-9), and the scales for the assessment of the 'positive' and 'negative' symptoms of schizophrenia (SAPS and SANS respectively). The dimensionality of the SAPS/SANS item scores and sub-scales was examined throughout the use of principal component analysis. RESULTS: The principal component solution that best fits the data obtained with the initial SANS/SAPS sub-scales reflects the existence of three different ('negative', 'positive', 'disorganisation') factors. The strategy adopted of repeating the analysis after extracting the principal components of the original sub-scales, revealed that although the nature and item composition of the initial 'negative' and 'disorganisation' factors were in general confirmed, the 'positive' dimension presented a more complex structure with at least two 'positive' ('Non-Paranoid' and 'Paranoid') independent factors. CONCLUSION: The psychopathological structure of the early stages of schizophrenia, as evaluated by the SANS/SAPS, is characterised by the presence of four dimensions: two 'positive', one 'negative' and one 'disorganisation'.

[Identification by typological analysis of distinct groups of schizophrenic patients. Applicability of a disorganized schizophrenia subtype]. / Identification par une analyse typologique de groupes distincts de patients schizophrènes. Pertinence d'un groupe désorganisé.

Since Crow, Andreasen et al. have described schizophrenia in terms of negative and positive symptoms, the dichotomic approach has been well established. As a matter of fact, factor analyses, especially principal components analyses, led with symptomatic specific scales, have proved their validity. But they have shown their limits too : some authors think that the dichotomic model fails to explain all of the schizophrenic psychopathology and that a third dimension including formal thought disorders, most of the time called "disorganization", should systematically be taken into account. In this study, the authors have hypothesized that a categorial approach could describe this "disorganization". Using a cluster analysis they investigated the existence of subtypes in a population including 136 schizophrenic patients assessed with the PANSS (Positive and Negative Syndrome Scale, Kayet al., 1987). The results suggested at least five subtypes: a pure positive subtype, characterized by high scores on items delusions, hallucinatory behavior, suspiciousness/persecution, and by a low score on conceptual disorganization item; a disorganized positive subtype, characterized by high scores on positive items, including conceptual disorganization item, and also high scores on unusual thought content and autistic preoccupation items; a negative subtype, characterized by high scores on negative items and low scores on positive items, including conceptual disorganization item; a mixed subtype, characterized by high scores on the most positive, negative and general psychopathological items; a residual subtype, characterized by low scores on all the positive, negative and general psychopathological items. The good validity of this analysis was showed since differences on a number of clinical characteristics were observed between the five clusters. These results demonstrated the oversimplication of the positive-negative dichotomy and the relevance of a disorganized subtype.

A factor analytic study of symptoms in acute schizophrenia.

The three-syndrome model of schizophrenic phenomenology has been well established in chronic illness. We report an attempt to replicate this concept in a sample of acutely unwell schizophrenic patients. Factor analysis was performed using PSE data collected within a week of admission from 114 patients who met DSMIII(R) diagnostic criteria for schizophrenia. Four main factors accounted for 58% of the variance. The first two factors closely resembled Liddle's disorganisation and psychomotor poverty syndromes. Hallucinations and delusions loaded separately under the third and fourth factors. To examine the validity of these four syndromes, the relationships between factor scores and other clinical data were examined. The disorganisation syndrome was associated with a history of multiple past admissions and a longer lifetime duration of in-patient treatment.

Cognitive inhibition and schizophrenic symptom subgroups.

Subgroups of patients with schizophrenia were examined in relation to repetition and semantic priming under conditions in which the prime stimulus was to be either attended to or ignored (unattended). Attended conditions normally would produce positive priming; and unattended conditions, negative priming (i.e., a delayed reaction resulting from inhibition of target information previously presented as to-be-ignored stimulus). Cluster analysis of participants' ratings on the Schedule for the Assessment of Positive Symptoms and the Schedule for the Assessment of Negative Symptoms revealed three subgroups that aligned broadly previous research citing with disorganization, reality distortion, and psychomotor poverty syndromes, and a fourth episodic subgroup. The Disorganization, Reality Distortion, and Episodic subgroups were associated with reduced, indeed reversed, negative priming in unattended priming conditions, whereas the Psychomotor Poverty subgroup exhibited the usual negative priming effect. Participants in the former three subgroups also exhibited reversed positive priming for the repetition condition, while the Psychomotor Poverty group displayed the expected positive priming effect. These results indicate that weakening of inhibitory processes may underlie both the reality distortion and disorganization dimensions of positive schizophrenic symptomatology, including the latent presence of these symptoms. In contrast, negative symptoms contributing to the psychomotor poverty dimension of schizophrenia are not linked to reduced inhibition. The association of positive symptom subgroups with reversed positive priming suggested that, for these participants, stimuli and task differences have an impact on the preattentive activation of information underlying such priming. It is proposed that a "reduced inhibition" model of schizophrenic symptomatology may need to be extended to account for influences on preattentive processing.

Cognitive disorders in the positive, negative, and disorganization syndromes of schizophrenia.

Recent factor-analytic studies have derived several trisyndromic models for schizophrenia, all based on the positive, negative, and disorganization syndromes. The goal of this study was to examine cognitive disorders in these three schizophrenic syndromes. The study group was composed of 40 schizophrenic patients consecutively admitted to the hospital due to a recrudescence of their symptomatology. They were selected on the basis of a semistructured interview, diagnosed with DSM-III-R criteria, and evaluated with scales for positive and negative symptoms. Their cognitive disorders were assessed with a battery of neuropsychological tests. The schizophrenic syndromes were weakly associated with cognitive performance through direct correlations and after correction for confounding variables. The disorganization and negative syndromes were more strongly associated with cognitive disturbances than was the positive syndrome, and both were associated with disturbances of visual-motor processes. Moreover, the disorganization syndrome was associated with disturbances in language and verbal memory and in time-controlled performance.

Structural and functional correlates of subsyndromes in chronic schizophrenia.

Recent psychopathological studies consistently identified a delusional, a negative, and a disorganized subsyndrome in chronic schizophrenia. The aim of our studies was to investigate the subsyndromes with respect to their underlying cerebral changes using computed tomography (CT) and positron emission tomography (PET). In a CT study 50 DSM III schizophrenics were subgrouped according to four factors identified by a factor analysis of BPRS ratings. This procedure identified three chronic clusters (delusional ideation, negative symptoms, and disorganization) and one cluster with a remitting course of the disorder. Both the negative and the delusional subsyndrome were associated with a widening of the frontal interhemispheric fissure. Disorganization was associated with neurological soft signs, an increased ventricle brain ratio, and width of the 3rd ventricle. The same subgrouping was applied in a 18F-deoxyglucose PET study of 79 neuroleptic free DSM III schizophrenic patients and 47 healthy controls. The delusional subsyndrome was associated with a decreased hippocampal function, while the negative subsyndrome showed a prominent hypofrontality and left temporal cortex changes. Both the delusional and the negative subsyndrome were associated with a decreased activity in the medial frontal gyrus in comparison to the other schizophrenic patients and the healthy controls. The disorganized subsyndrome was characterized by an overactivity in the parietal cortex and motor strip and a decreased activity in the corpus callosum. These findings support the differentiation of three subsyndromes in chronic schizophrenia. The subsyndromes seem to be characterized by deviant patterns of cerebral alterations, rather than deficits in a single location.

Outcome and family study of the subtypes of schizophrenia in the west of Ireland.

OBJECTIVE: The authors sought to clarify differences in outcome and familial psychopathology among the classical subtypes of schizophrenia. METHOD: In the epidemiologically based Roscommon Family Study, personal interviews were conducted with 88% of traceable living probands (N = 415) an average of 16 years after illness onset and with 86% of traceable living first-degree relatives (N = 1,753). Probands meeting the DSM-III-R criteria for schizophrenia were subtyped by DSM-III-R and ICD-9. RESULTS: By both diagnostic systems, age at onset differed significantly across subtypes, being earliest in the subjects with the hebephrenic and catatonic subtypes and latest in the paranoid subjects. The probands with the paranoid subtype had substantially better outcome, especially in occupational functioning and capacity for self-care. The DSM-III-R criteria for paranoid schizophrenia were considerably more successful than the ICD-9 criteria in selecting good-outcome cases. Neither the risk for schizophrenia nor the risk for schizophrenia spectrum disorders significantly differed in relatives as a function of the proband subtype. The subtypes of schizophrenia did not "breed true" within families. CONCLUSIONS: Paranoid schizophrenia, especially when narrowly defined, as in DSM-III-R, has a substantially better outcome than other subtypes. From a familial perspective, 1) paranoid schizophrenia is not a milder form of schizophrenia and 2) catatonic schizophrenia is probably closely related to typical schizophrenia. The subtypes of schizophrenia are not, from a familial perspective, etiologically distinct syndromes.

Age at onset in subtypes of schizophrenic disorders.

Age at onset and sex differences in the age at onset were investigated in the schizophrenic subtypes of 200 patients. Significant differences in the age at onset were observed among these subtypes; the disorganized subtype demonstrated the earliest and the paranoid the latest onset. The mean age at onset of all female patients was significantly greater than that of the male. Specifically, in the paranoid subtype the onset for men occurred earlier than for women. Conversely, in the disorganized subtype the disorder appeared earlier in women. There was no significant sex difference in the age at onset in the undifferentiated and the residual subtypes. In the paranoid subtype most men developed the disease before age 30 (72%), whereas women had an even distribution of the onset before and after 30. Ninety-six patients admitted for the first time demonstrated findings similar to those of the total sample. The data provide additional information on the phenotypic expression of the subtypes of schizophrenic disorders and indicate the necessity for further demographic and genetic studies to delineate the underlying defect.

Heterogeneity in schizophrenia: an extended replication of the hebephrenic-like and paranoid-like subtypes.

Hebephrenic-like (H) and paranoid-like (P) subtypes of schizophrenia have previously been described by Farmer et al. (1983, 1984). The stability of this subtypology of schizophrenia was explored using multivariate statistical techniques on a large independent data set. Both a discriminant function analysis and an admixture analysis produced strong evidence for a bimodel distribution of scores consistent with the H-like and P-like subtypes.

Positive, negative, and disorganisation factors from the Schedule for Affective Disorders and Schizophrenia and the Present State Examination. A three-factor solution.

The use of items from the Schedule for Affective Disorders and Schizophrenia and from the Present State Examination scales for assessing positive and negative symptoms in schizophrenia was examined using factor analysis. The factorial structure of the items which putatively assess positive and negative symptoms was examined. A three-factor solution was obtained with factors identified as: a negative symptom factor (factor 1); a positive symptom factor (factor 2); a 'disorganisation' factor (factor 3), consisting primarily of items related to disordered thinking. A solution which was highly similar in important loadings was obtained with an independent sample of patients. High correlations of the rotated factors with the external criteria supported the interpretations of the factors. The results indicate that symptoms generally classified as negative or positive are factorially independent. Furthermore, a disorganisation factor, consisting of items previously included in positive and negative symptoms factors, is necessary for a full representation of the factor structure.