Table Of ContentKarl Leonhard
Classification of Endogenous Psychoses
and their Differentiated Etiology
Second, revised and enlarged edition
Edited by Helmut Beckmann
Springer-Verlag Wien GmbH
Prof. Dr. med. Dr. h. c. Helmut Beckmann
Psychiatrische Klinik und Poliklinik, Universit:âts-Nervenklinik,
Wiirzburg, Deutschland
Prof. Dr. Karl Leonhardt, Berlin
Translated from German by Charles H. Cahn
Originally published as A ufteilung der endogenen Psychosen
und ihre diJJerenzierte Atiologie, 7. neubearbeitete und ergiinzte Auflage
© 1995 Thieme, Stuttgart
The first English edition was published by Irvington Publishers, Ine., © 1979
This work is subject to copyright.
AlI rights are reserved, whether the whole or part of the material is concerned,
specifically those of translation, reprinting, re-use of illustrations, broadcasting,
reproduction by photocopying machines or similar means, and storage in data banks.
© 1999 Springer-Verlag Wien
Originally published by Springer-Verlag Wien New York in 1999
Softcover reprint of tbe hardcover 2nd edition 1999
Typesetting: Bernhard Computertext KG, A-I030 Wien
Graphic design: Ecke Bonk
Printed on acid-free and chlorine-free bleached paper
SPIN: 10711564
Library of Congress Cataloging-in-Publication Data
Leonhard, Karl, 1904-
[Aufteilung der endogenen Psychosen und ihre differenzierte Ătiologie, English]
Classification of endogenous psychoses and their differentiated etiology /
Karl Leonhard. - - 2nd, rev. and enlarged ed. / edited by He1mut Beckmann. p. cm.
Previously published: Classification of endogenous psychoses. New York: Irvington
Publishers, 1979.
"Originally published as: Aufteilung der endogenen Psychosen und ihre differenzierte
Ătiologie, 7. neubearbeitete und ergănzte Auflage. © 1995 Thieme, Stuttgart" - - CIP t.p.
verso. Inc1udes bibliographical references and index.
ISBN 978-3-7091-7308-4 ISBN 978-3-7091-6371-9 (eBook)
DOI 10.1007/978-3-7091-6371-9
1. Psychoses Classification. 1. Beckmann, Helmut, 1940-.
II. Leonhard, Karl, 1904-Aufteilung der endogenen Psychosen. English. III. Title.
RCS12.L413 1999
616.89'001'2--dc21
ISBN 978-3-7091-7308-4
Editor's Comment
Halfa century ago KOLLE spoke about the "Oracle ofDelphi ofthe Endoge
nous Psychoses". Since then in spite of all innovations and technological
achievements in the pastdecades this pronouncementhas notlostanything
ofits significance and its application to the presentday research situation.
Mental andemotional disordersbelongto the large groupof"diseasesof
the people". From the public health pointofview they are ofextraordinary
import for every community. Accordingly, some countries have generously
supported research efforts in the neurosciences as well as in the physical
sciences with the aim ofachieving tangible progress in prevention and pre
cise diagnosis, aswell as rehabilitation. Suchefforts have amongstothers led
to the declaration of the "Decade of the Brain" in the United States and
more recently to thatofthe "World Decade ofthe Brain" in which all inter
national societies concernedwith the problem ofmental health and rehabi
litation have setthe objective ofintroducingandcarryingoutmore effective
measures.
However public support should not be overemphazised. Compared with
cardiovascular diseases, rheumatic disorders, neurological conditions such
as multiple sclerosis etc. the supportfor research in the psychoses is compa
rablyscantyand in manycountries oftheworldcompletelyabsent.
Psychiatry in the true sense ofthe word has achieved objective progress
only since, beginning with the Age ofEnlightenment, it has become more
closely allied with the natural sciences, and through the influence ofsome
prominent representatives, such as PINEL in France and GRIESINGER in Ger
many, become associatedwith facuIties ofmedicine. This desirable situation
has only been attained in some parts ofthe world; setbacks are continually
experienced and peculiaramalgamationstake placebetween the natural sci
ences and shamanism.
With the 7th new edition of Karl LEONHARD'S "Classification of
EndogenousPsychosesandtheirDifferentiatedEtiology" the"World Decade
oftheBrain",proclaimed in 1990approachesitsmiddle. Resultsfrom theso
called endogenous psychoses have so far been sparse. It is true that some
symptoms ofthese disorders maybe relieved with neuroleptic dmg therapy;
cures however have not been achieved. Nothing is known about effective
prevention. For the affective disorders the introduction oflithium as a pro
phylactic measure is noteworthy, but even this treatment is not entirely reli
able and may be associated with undesirable side effects placing an undue
burden on the patient. The treatment ofendogenous psychoses has almost
VI Editor'sComment
stood still in the last three decades. Itis still necessary to use partly effective
and insufficiently reliable chemical substances in our treatment. In spite of
all the enticements ofmodern marketingstrategies better medications have
notyet beenfound.
It is worth remembering that already in the 19th century (for instance
KAI-lLBAUM andseveral French authors) a numberofnosological entitieshad
been describedamongtheendogenouspsychoses. In thesamecentury, how
ever, researchers such as Heinrich NEUMANN and Wilhelm GRIESINGER had
postulated a "unitarypsychosis".
Emil KRAEPELIN (1856-1925) proposed a partial compromise by separat
ing the large field of dementia praecox with unfavorable prognosis from
the field ofmanic-depressive conditions with favorable prognosis. This cre
ation ofa bimodal concept led to a dichotomy which for research has not
proved to be veryfruitful up to the present time. In spite ofthis subdivision
KRAEPELIN described masterfully many subcategories, taking into acount
cross-sectional and longitudinal symptomatology which even today may be
considered to be quite valid, but towards the end of his life he lost the
strength to develop this classification further. Eugen BLEULER (1857-1939)
took over the concept of dementia praecox/manic-depressive illness, but
completely ignored the prognostic aspects which KRAEPELIN (apart from a
few exceptions) had held to be ofgreatestvalue. Thus he combined a large
proportion of psychoses, which KRAEPELI had included under the manic
depressive illnesses, with the conditions which he now called "schizophre
nias" or "schizophrenia". He himselfwas convinced that he was dealingwith
several nosological entities; nevertheless it is a tragic aspect of his creative
research that all his life he was looking for so-called "basic disturbances" of
"schizophrenia", which ofcourse he did notfind, because they do not exist.
BLEULER did not bluntly reject FREun's psychoanalysis; his positive attitude
helped byAdolfMAYER resulted in his being made to feel welcome in Anglo
American psychiatry. Furthermore his cross-sectional symptomatological
description, leaving aside prognosis, was accepted there more easily, for
example byMAYER-GROSS.
During the lastseveral decades atcertain intervals oftime and with good
intention classification systems have been worked out by psychologists and
psychiatristsbymeansofvotingand consensus; descriptions ofthese systems
come into the handsofmental health professionals in great regularityin the
form of authoritative guidelines. All too easily it is being overlooked that
behind it all no progress is made in research, merely restructurization. The
latterhas notbeen derivedfrom lifelongobservations ofpatients. Therefore
from the scientific pointofviewthis remainsat leastquestionable. Interrater
reliability keeps on being stressed at the expense ofclinical validity. It even
happened that clinical investigations requiring a high degree ofknowledge
and experience possessed by only the most skilful were delegated to
"trained" students, psychologists, and scientific assistants in their first years
ofapprenticeship. Ofcourse such mathematically attractive results cannot
provide satisfaction.Witness the fruitlessness ofourdecades long research.
}.'ditorsComment VTI
Contemporaneouslywith KRAEPELIN'S efforts CarlWERNICKE (1848-1905)
in Berlin, Breslau and later Halle worked in the field ofcentral neurology
(particularlyofaphasia) aswell as in thefield ofdescriptive psychiatry, From
his findings in psychopathology he repeatedly postulated a "theory of dis
junction" ("Sejunktionstheorie"), thatis, an interruption ofthe connections
between neural systems, leading either to a loss of functions, an excess of
function or a faulty function. This disjunction may, for example in the area
of psychomotility, lead to akinesia, hyperkinesia, or parakinesia. He sug
gested thata similar process occurred in thinkingand in disturbances ofthe
will. In so doinghe found a powerfulopponentin KarlJASPERS, who labelled
him as a "brain mythologist".JASPERS had evidently overlooked the essential
element in Wernicke's research, that is the careful elaboration of psy
chopathological conditions in cross-section as well as in their longitudinal
course; even today in their precision WERNICKE'S descriptions are of great
value. Among other surviving concepts WERNICKE coined the terms "akine
sia", "hyperkinesia", "anxietypsychosis".
His pupil Karl KLEIST (1879-1960) followed WERNICKE in neurology as
well as in psychiatry and psychopathology; by means ofextensive studies of
patients with brain trauma, KLEIST thoroughly confirmed and expanded
WERNICKE'S observations (TEICHMANN 1990).
Differences between WERNICKE and KRAEPELIN became more apparent
leading to a certain antagonism between them. This was continued with
KLEIST, who never accepted such a gross division into two as KRAEPELIN and
his pupils had proposed. As well he doubted the untiy ofmanic-depressive
illness and asked his pupil Edda NEELE to investigate monopolar/bipolar
depressions (1949). Furthermore he separated the cycloid psychoses from
the field ofmanic-depressive illness and from a part ofthe schizophrenias.
Fromhisobservationsarederivedmasterfulpsychopathologicaldescriptions
which can hardly be further improved. Unfortunately he lacked the time to
summarize all his psychopathological investigationsso that now they have to
be read in various original papers.
Karl LEONHARD wasa pupil ofKLEIST. In 1936he came from the Gabersee
psychiatrichospital toFrankfurt/Main,and broughtwith him theconceptof
"defect schizophrenic clinical pictures". He thus became a recognized lec
turer (in German "Habilitation") at Frankfurt University with the full sup
portofKLEIST. Here was found for the time a clearseparationofa large por
tionof"schizophrenic"diseases,whichatfirstKLEISTbutlateralso LEONHARD
did not include under the group ofschizophrenias, butwere considered as
"system diseases" of the brain. These "systematic" schizophrenias were
thought to have originated in a weakness either caused by a constitutional
hereditary disposition or by environmental factors. They have a chronic
insidious onset and their course is progressive with poor prognosis. In fact
investigations for several decades, already introduced at KLEIST'S clinic,
revealed that evidently these conditions with a deleterious course but little
genetic predisposition showed nosologically a sharply limited characteriza
tion. After early admixtures of accessory symptoms such as hallucinations
VIII t.aitor'sComment
and delusions they become stable some years later, and may be identified
againandagain whatever therapeutic proceduresare used. These hebephre
nias, paraphrenias, and catatonias show entirely different clinical pictures
whichcanonlybelearnedand recognized byapplyinga highdegreeofintel
lectual effort. Nevertheless the latter is worthwhile, since here we do not
have hereditary forms of mental illnesses before us and thus can avoid a
source oferrorin therapyand research.
Ofcourse Karl LEONHARD'S etiological considerations which in this book
he points out in a highly differentiated manner for each of his diagnostic
entities may be held to be somewhat imaginative speculations. For all that,
theyare based on his conscientious observations and passionatelyingenious
reflections throughout the decades. Nevertheless he himself accepts that
there may be otherways ofexplaininghisfindings. Comparisonsofhisviews
on earlychildhood catatoniawith those in the literature mustbe considered
to be highlyweighted in hisfavorand mayturn outto beveryrelevantin the
education offuture generations.
Theso-called"unsystematicschizophrenias" (periodiccatatonia,affective
paraphrenia, cataphasia) are of great scientific significance in so far as in
them heredity plays a striking role, thus leading themselves to modern
genetic research par excellence. Their course at the beginning is usually
stormy, later there are often phases with the development of more or less
clear-cutdefects. When strongaffective elements are presentsymptoms may
bewell controlled bymeans ofmodern neuroleptic therapyand thus offera
good therapeutic field for modern pharmacotherapy. Nevertheless it must
be mentioned critically that true cures are hardly possible. These illnesses
show, even with few symptoms, the formation of typical defects (periodic
catatonia: apathy; affective paraphrenia: mistrust, suspicion; cataphasia: per
plexity, poverty ofaffect). Even here LEONHARD, beside the striking genetic
findings, expressed important thoughts concerning the role ofparents and
siblings during the development of the patient's childhood; even if these
thoughts are notconvincing theyare at least noteworthy.
With regard to the cycloid psychoses (anxiety-happiness psychosis,
excited-inhibited confusion psychosis, hyperkinetic-akinetic motility psy
chosis) LEONHARD in building on the research ofhis predecessorsWERNICKE
and KLEISTseesthings ratherdifferently. Hedeserves thecreditofhavingdif
ferentiated these from the other forms of psychoses. He describes precise
psychopathological clinical pictureswhich at times temporarilyoverlapwith
othercycloidpsychoses, sothattheyare notalwayseasilyrecognizedincross
section even byexperienced observers. Occasionally there are transitions, at
least of short duration, with unsystematic schizophrenias or even manic
depressive illness. This diagnostic problem may however be solved in most
cases ifthe longitudinal development ofthe condition is carefullyanalysed.
What is important for therapy is that medications in practice produce only
symptomatic improvementanddo nothave any real influenceon the course
of the psychosis. Cycloid psychoses also show spontaneous remissions and
may not leave any defect behind. Continued medication with neuroleptics
Editor'sComment IX
during the healthy periods are more a hindrance than a help and may lead
to toxic side effects which may disable the patient in his every day life and
brand him as mentally ill. Because ofthis LEONHARD has made a passionate
appeal for the careful differentiation of the cycloid from the other psy
choses. The prognosis, which is exceedingly important not only for the
patient but also for his family may be ofgreat value, keeping in mind how
much the burden ofmentalillness iscarriedbythe whole family. To be sure,
greatcaution is indicated with regard to predicting the duration ofa phase,
since there are cycloid psychoseswhich lastfrom a few days to several years.
Nevertheless there is good reason in the last analysis to retain a favorable
prognosis. The familiar incidence in contradiction to the unsystematic psy
chosesislow (about4%). Here toohisetiologicalreflectionsin termsoffam
ily and siblings are interesting, and can only be understood on the basis of
LEONHARD'S collective works (Biopsychology of Endogenous Psychoses,
1970; Biological Psychology, 1993). They will be rejected by many. But this
does not in the least diminish the value ofthe exact descriptions and con
sideration ofhereditaryfactors offered here.
The conceptofmanic-depressive illnesswith its usual bipolar course was
taken over by KLEIST and by LEONHARD from KRAEPELIN, and required no
essential additions. However LEONHARD differentiated it clearly from pure
melancholiaand pure depression. This had always been surmised by KLEIST,
butwasconfirmedbyEddaNEELE (1949),and then proved byLEONHARDand
his co-workers from their investigations of families through observing the
clinical and genetic characteristics. There is thus no doubt that Karl LEON
HARD has conclusively proved that the discovery of the monopolar/bipolar
dichotomy of manic-depressive illness in its phenomenology and genetics
was valid. ANGST (1966), PERRIS (1966) and WINOKUR (1969) in their investi
gations have always confirmed this even without having undertaken a phe
nomenological cross-sectional and longitudinal analysis. On the basis ofhis
investigations Karl LEONHARD assumes for manic-depressive illness as differ
entiated by him an important hereditary flaw, equivalent to genetic domi
nance. No connection with the X-chromosome was found by him in his
extensive material despite such proposals by several authors. Even the dis
crepancyfound in monozygotic twins with regard to the incidence ofthese
illnesses he explains as due to a different affective lability, which does not
have to be genetically inherited, butwhich may eventually promote or pre
ventthe onsetofthe illness in one orthe otherofthe twin partners. This he
mentions primarilyas a hypothesis in order tostimulate discussion.
The separation of mania occurring in phases has likewise been recog
nized all over the world. These are rather rare diseases to which particular
attention ought to be paid; this happens all too infrequently. LEONHARD has
quite independently separated five pure depressions: agitated (also trans
lated as "harried"), hypochondriacal, self-tortured, suspicious, apathetic, as
wellasfive pureeuphorias: unproductive, hypochondriacal, exalted, confab
ulatory, indifferent. These clinical picturesoccurinfrequently, butare being
seen again and again by experienced clinicians, sometimes misdiagnosed as
x Editor'sComment
atypical depression or as neuroses. But Karl LEONHARD has described them
with such sharp circumscription that the diagnoses cannot be missed from
observation. It is quite incomprehensible that these characteristic clinical
pictures continue to be pushed this way or that way diagnostically. Here he
postulated in each case an affliction ofa particularemotionallayerin which
pathological thinking is occasioned by the type of pathological affect. This
he underscores in his book "Biological Psychology" where hegains valuable
insights from the pure depressions, the pure euphorias, as well as the sys
tematic schizophrenias as derived from his observations of the symptoms.
These insights oughtto help modern scientific psychologyemerge from the
blind alleyoffruitless research.
The question has often been asked why the "WERNICKE-KLEIST-LEON
HARD-SCHOOL" ofpsychiatryhas notprevailed internationally. There are sev
eral answers to this question: first the fact thatWERNICKE died earlyand thus
was unable to defend his pointofviewfrom thatofthe influentialKRAEPELIN;
secondly, critics such as JASPERS (who worked in psychiatry for only a few
months), and manyotherswho branded him and his pupil KLEIST as "brain
mythologists" and ignored him aswell.
Against the differentiated nosology of the "WERNICKE-KLEIST-LEON
HARD-SCHOOL" numerous other objections have been raised by essentially
uninformed critics. Manymodern psychiatrists reproached LEONHARDsaying
that his nosological entities were too subjective, they had been elaborated
from clinical observations, and lacked "objective" confirmation. He was also
criticized in that he did not develop any "rating scales" by means ofwhich
individual clinical pictures could have been identified in "operationalized"
form by third parties. To counter these criticisms is the fact that LEONHARD
had personally with his co-workers examined several hundreds, even thou
sands ofpatients before each nosological entity was elaborated. His investi
gationsspanningmanydecades,wereconductedbyhim personallyandwere
meticulously described by him in writing; in his "Frankfurt series" they con
sistedofseveral hundredcases, in his "Berlin series" of1465cases. Ofcourse
the figures ofthe differentiated clinical pictures vary greatly, from the very
frequent manic-depressive illness and the cycloid psychoses to the single
forms of unsystematic and systematic schizophrenias. Single subforms he
observed onlyoccasionally,afactwhich he mentionseverytime. In rare cases
(e.g. indifferent euphoria) he presented only a few case histories.
Complicated combined systematic forms likewise were seen by him in rela
tively few cases, because these were almost always being caredfor in psychi
atric institutions because oftheir severity. This has led to criticisms that he
had modelled individual categories, as ifon a drawing board. From observa
tions that myco-workers and I were able to make regarding his explorations
ofmany years I cannot remember a single case in which he was unable to
describe a type ofillness in all its psychopathological differentiations in the
way he hadsuggested. In thisway itbecame understandable again andagain
why his method ofdiagnosing remained closed indefinitely to so many psy
chiatrists. The diagnosis ofhis nosological categories is complete only ifall
Editor'sComment XI
symptoms found in his descriptions can be diagnosed in the patient. Indi
vidual mainly qualitative changes exclude the correct diagnosis. Therefore
in hisdescriptionsone isnotdealingwithonlyclinicalimpressions,artfulcir
cumscriptions, reminiscences or suppositions, but with psychopathological
descriptions made and modified in their empirical exactitude for decades,
representing the most important elements in a most striking manner. Thus
the most careful operationalizations were practised, in which firm associa
tions ofsymptoms were described. It is unthinkable that symptoms the way
heseesthemcan be removedfrom the groupings toform otherclinical enti
ties. Each disturbance of thinking, for instance in systematic paraphrenia,
has its own characteristic form, and can be found only with this condition.
The same applies to auditory hallucinations which may occur in practically
all psychiatric conditions, butwhich for LEONHARD acquired their nosologi
cal significance only in their definite firm legitimate symptomatic connec
tion, that is, a syndrome. Deviation from thisfirm conformityor inattentive
ness will always lead to the wrong diagnosis. Numerous scientists have tried
to "operationalize" LEONHARD and have always failed, because by doing so
less exactorless appropriate pictures arose. Ofcourse this increases the dif
ficulty ofaccepting and transmitting his point ofview. In comparison with
neurology in which one is essentially dealing with motor and sensory phe
nomena whose differential diagnosis presents enormous problems, why
should these be any lesswhen dealingwith the highest human functions? In
neurologyadditional somatic findings (imagingand laboratory techniques)
considerably facilitate diagnosis. Here in psychiatry it is to be hoped that
soon with the help of modern scientific procedures additional diagnostic
techniques may bring more certainty to this field. In the meantime we have
to fall backon the painstaking road ofpsychopathological differentiation in
order to obtain the most homogeneousgroupsfor investigation.
Early results in clinicalgenetics have alreadybeenshown to be impressive
by means of such a nosological differentiation (FRANZEK and BECKMANN
1991). Differential methods oftherapy as well have found a more sensible
application than ifthey had been used in an undifferentiated manner for a
supposedlyunitary psychotic continuum (BECKMANN etal. 1992).
With regard to prognosis LEONHARD'S classification of endogenous psy
choses brings enormous advantages, thereby avoiding many misjudgements
which have contributed to givingour professionsuch bad publicity. Further
more it protects usfrom deceptive illusions, encourages us in our therapeu
tic endeavours, and keeps in check exaggerations which occur here and
there.
In research concerningthe etiologyofendogenous psychoses the type of
differentiated psychopathology according to LEONHARD is indispensable.
Here too some early encouraging results have been obtained, which have
been described partially byLEONHARD himself (UNGVARI 1993).
The possibilities ofdanger because ofearly childhood isolation in single
child families or distinct position in the order ofsiblings are shown impres
sively. Other investigators found distinct environmental influences in the
