Kraepelin's Final Views on Dementia Praecox

A narrative review of nosology and the concept of schizophrenia: criticism and proposal

Schizophrenia diagnostics have evolved to adapt to clinical needs and scientific advances, and the current denominations emerged at the beginning of the twentieth century. Most problems arise while integrating clinical experiences, based on historical psychopathological descriptions, with emerging translational neuroscience research. This study aimed to evaluate the state-of-the-art critics of the current schizophrenia concept and their recommendations for new concepts. We performed a narrative review of the literature and searched for studies published in English in PubMed in the last 2 years which discussed the diagnosis of schizophrenia. Two authors independently selected the studies after analyzing the abstracts. Subsequently, studies were selected for this review by consensus. Twenty-six studies were selected, and all authors, except two, had restrictions on the current categorical model for the diagnosis of schizophrenia owing to the heterogeneity of symptomatology and high frequency of comorbidity. Eight studies proposed changes to the concept of schizophrenia. The central proposition was to adopt psychotic syndrome as a core feature instead of the current concept of schizophrenia. We synthesize these proposals using psychosis as a spectrum that includes schizophrenia as a more severe case at the end of the spectrum.

Identifying reversible psychiatric dementia mimics in new memory clinic outpatients

Background

Timely identification of reversible conditions that mimic dementia is critical in memory clinic practice. However, psychiatric conditions as potential dementia mimics have not been studied as thoroughly as neurological ones, and detailed data on their reversibility remain limited.

Objective

To identify reversible psychiatric dementia mimics.

Methods

A retrospective chart review was conducted on 749 new outpatients to investigate etiologies, progression rates, a neuropsychological assessment, cognitive and functional levels, and potential reversibility, categorized by psychiatric and neurological conditions. Cases showing cognitive reversibility following treatment were also identified. Comparisons were made based on the presence or absence of potential reversibility, as well as actual reversibility.

Results

Among the 749 individuals, 121 (16.2%) had potentially reversible conditions: 75 psychiatric and 46 neurological. Psychiatric conditions included depression, schizophrenia and delusional disorders, developmental disorders, alcohol use disorder, and dissociative and anxiety disorders. Compared to individuals without potentially reversible conditions, individuals with psychiatric conditions were younger, had a faster progression rate, and demonstrated higher cognitive function. Of the individuals who had mild cognitive impairment or dementia mimic, 6 (0.9%) showed complete cognitive resolution (3 cases) or partial cognitive improvement (3 cases). These 6 cases included two individuals with psychiatric conditions manifesting psychotic features.

Conclusions

While rare, reversible psychiatric dementia mimics highlight the importance of comprehensive evaluations in memory clinics, particularly for younger individuals experiencing rapid cognitive decline. The infrequency of reversibility may reflect a strong association between these potentially reversible conditions and dementia risk factors, or their role as prodromes of dementia itself.

Preventing disease progression in schizophrenia: What are we waiting for

Despite research advances and progress in health care, schizophrenia remains a debilitating and costly disease. Onset occurs typically during youth and can lead to a relapsing and ultimately chronic course with persistent symptoms and functional impairment if not promptly and properly treated. Consequently, over time, schizophrenia causes substantial distress and disability for patients, their families and accrues to a collective burden to society. Recent research has revealed much about the pathophysiology that underlies the progressive nature of schizophrenia. Additionally, treatment strategies for disease management have been developed that have the potential to not just control psychotic symptoms but limit the cumulative morbidity of the illness. Given the evidence for their effectiveness and feasibility for their application, it is perplexing that this model of care has not yet become the standard of care and widely implemented to reduce the burden of illness on patients and society. This begs the question of whether the failure of implementation of a potentially disease-modifying strategy is due to the lack of evidence of efficacy (or belief in it) and readiness for implementation, or whether it's the lack of motivation and political will to support their utilization. To address this question, we reviewed and summarized the literature describing the natural history, pathophysiology and therapeutic strategies that can alleviate symptoms, prevent relapse, and potentially modify the course of schizophrenia. We conclude that, while we await further advances in mental health care from research, we must fully appreciate and take advantage of the effectiveness of existing treatments and overcome the attitudinal, policy, and infrastructural barriers to providing optimal mental health care capable of providing a disease-modifying treatment to patients with schizophrenia.

On the improvement of schizophrenia detection with optical coherence tomography data using deep neural networks and aggregation functions

Schizophrenia is a serious mental disorder with a complex neurobiological background and a well-defined psychopathological picture. Despite many efforts, a definitive disease biomarker has still not been identified. One of the promising candidates for a disease-related biomarker could involve retinal morphology , given that the retina is a part of the central nervous system that is known to be affected in schizophrenia and related to multiple illness features. In this study Optical Coherence Tomography (OCT) data is applied to assess the different layers of the retina. OCT data were applied in the process of automatic differentiation of schizophrenic patients from healthy controls. Numerical experiments involved applying several individual 1D Convolutional Neural Network-based models as well as further using the aggregation of classification results to improve the initial classification results. The main goal of the study was to check how methods based on the aggregation of classification results work in classifying neuroanatomical features of schizophrenia. Among over 300, 000 different variants of tested aggregation operators, a few versions provided satisfactory results.

Prioritization of Psychopathological Symptoms and Clinical Characterization in Psychiatric Diagnoses: A Narrative Review

Importance

Psychiatry mainly deals with conditions that are mediated by brain function but are not directly attributable to specific brain abnormalities. Given the lack of concrete biological markers, such as laboratory tests or imaging results, the development of diagnostic systems is difficult.

Observations

This narrative review evaluated 9 diagnostic approaches. The validity of the DSM and the International Classification of Disorders (ICD) is limited. The Research Domain Criteria is a research framework, not a diagnostic system. The clinical utility of the quantitatively derived, dimensional Hierarchical Taxonomy of Psychopathology is questionable. The Psychodynamic Diagnostic Manual Version 2 follows psychoanalytic theory and focuses on personality. Unlike the personality assessments in ICD-11 or DSM-5's alternative model, based on pathological extremes of the big 5 traits (extraversion, agreeableness, openness, conscientiousness, and neuroticism), it lacks foundation in empirical evidence. Network analytic approaches are intriguing, but their complexity makes them difficult to implement. Staging would be easier if individually predictive biological markers were available. The problem with all these new approaches is that they abstract patient experiences into higher-order constructs, potentially obscuring individual symptoms so much that they no longer reflect patients' actual problems.

Conclusions and Relevance

ICD and DSM diagnoses can be questioned, but the reality of psychopathological symptoms, such as hallucinations, depression, anxiety, compulsions, and the suffering stemming from them, cannot. Therefore, it may be advisable to primarily describe patients according to the psychopathological symptoms they present, and any resulting personal syndromes, embedded in a framework of contextual clinical characterization including personality assessment and staging. The DSM and ICD are necessary for reimbursement, but they should be simplified and merged. A primarily psychopathological symptoms-based, clinical characterization approach would be multidimensional and clinically useful, because it would lead to problem-oriented treatment and support transdiagnostic research. It should be based on a universally used instrument to assess psychopathology and structured clinical characterization.

The origins of catatonia - Systematic review of historical texts between 1800 and 1900

Since January 1st 2022, catatonia is (again) recognized as an independent diagnostic entity in the 11th revision of the International Classification of Diseases (ICD-11). This is a relevant time to systematically review how the concept of catatonia has evolved within the 19th century and how this concept changed under the influence of a wide variety of events in the history of psychiatry. Here, we systematically reviewed historical and modern German and English texts focusing on catatonic phenomena, published from 1800 to 1900. We searched five different electronical databases (https://archive.org, www.hathitrust.org, www.books.google.de, https://link.springer.com and PubMed) and closely reviewed 60 historical texts on catatonic symptoms. Three main findings emerged: First, catatonic phenomena and their underlying mechanisms were studied decades before Karl Ludwig Kahlbaum's catatonia concept of 1874. Second, Kahlbaum not only introduced catatonia, but, more generally, also called for a new classification of psychiatric disorders based on a comprehensive analysis of the entire clinical picture, including the dynamic course and cross-sectional symptomatology. Third, the literature review shows that between 1800 and 1900 catatonic phenomena were viewed to be 'located' right at the interface of motor and psychological symptoms with the respective pathophysiological mechanisms being discussed. In conclusion, catatonia can truly be considered one of the most exciting and controversial entity in both past and present psychiatry and neurology, as it occupies a unique position in the border territory between organic, psychotic and psychogenic illnesses.

Reshaping the diagnostic borders: Historical analysis of the diagnostic changes following the introduction of the schizophrenia concept

BACKGROUND

Although the concept of schizophrenia is still widely presented as having replaced that of dementia praecox, studies have shown that the former was broader than the latter, resulting in a more complex diagnostic redistribution. However, this is poorly documented by quantitative approaches.

AIMS

We sought to test the hypothesis that the use of the concept of schizophrenia had caused a diagnostic redistribution and to quantify it.

METHOD

A retrospective study, based on admission register archives of the Strasbourg University Clinic of Psychiatry was conducted. The frequency of diagnoses given to patients were examined at two key time periods: one before (TP1) and one after (TP2) the introduction of the schizophrenia concept (established between 1926 and 1928). Eight main diagnoses related to schizophrenia were considered.

RESULTS

Patients diagnosed with schizophrenia at TP2 mainly received the diagnoses of dementia praecox but also depression, hebephrenia, manic depressive illness, hysteria, paraphrenia, catatonia and mania at TP1. Dementia praecox and hebephrenia were the most relayed by schizophrenia. Bayesian sensitivity analyses confirmed the robustness of our data against distinct scenarios challenging our hypothesis.

CONCLUSIONS

Our results confirm the broadening of the concept of schizophrenia compared to that of dementia praecox but also qualify the different concepts supposed to have been impacted. They provide unique quantitative data that define the contours of the diagnostic redistribution thus provoked. They also give relevant input in the current context where the need to rethink the DSM/ICD concept of schizophrenia is still debated.

Relation of Vitamin D levels with positive and negative symptoms of schizophrenia - A hospital based cross-sectional comparative study

Background

The association between altered serum Vitamin D levels and schizophrenia has been an area that has evoked a recent fervor. The neurohumoral and neuro immunomodulatory functions of Vitamin D might have a role to play in understanding the causation of the disease and thus appear promising in the diagnostic and therapeutic frontiers of the disease.

Aims and Objectives

We aimed to estimate and compare serum Vitamin D levels in drug-free cases of schizophrenia and in healthy control groups. The comparison was also made among the subgroups of positive and negative schizophrenia.

Materials and Methods

The study, a hospital-based cross-sectional comparative study was carried out in the Department of Psychiatry, in a hospital in Assam over a period of 1 year. Fifty drug-free subjects of schizophrenia (Group A) diagnosed and confirmed according to International Classification of Diseases 10 were selected by consecutive sampling and 50 age and sex frequency-matched subjects (Group B) were selected from the healthy population. The cases (Group A) were divided into positive and negative groups (Group A1 and A2) based on the composite scoring of the Positive and Negative Syndrome Scale. After approval from the institutional ethics committee and obtaining written informed consent, Vitamin D levels were assessed in both groups of cases and controls and comparison was made.

Results

After statistical analysis, it was seen that males were more in proportion and mostly in the age group of 20-39 years. The median Vitamin D level among the cases was 12.45 ng/mL and that among controls was 20.03 ng/mL which was statistically significant (P value .00932). Among the positive and negative schizophrenia subgroup, there was no statistically significant difference in Vitamin D levels at means of 16.54 ng/mL and 16.25 ng/Ml, respectively. The variation in Vitamin D levels in schizophrenics and the healthy population is thus discernible.

Conclusion

It can be said that serum Vitamin D levels were significantly low in people with schizophrenia compared to the general population. Furthermore, it is seen that mean Vitamin D status is similar in both the groups of positive and negative schizophrenia negating the possibility of alteration of Vitamin D levels depending on the differences in symptomatology or in pathophysiology of the two groups.

Older adults with schizophrenia and dementia: Analysis of a national dataset

OBJECTIVES

Individuals with schizophrenia develop dementia in late life at higher rates than the general population. This is arguably explained by high rates of chronic medical conditions and exposure to antipsychotic medications. This risk has implications for public health. We aimed to test this in a large New Zealand database.

METHODS

Participants in this study were New Zealanders aged 65 years or older who had an interRAI assessment completed during the study period (July 2013-June 2020). This cohort study analysed data from 168,780 individuals. The majority were European (87%), and mostly assessment was for home care (86%).

RESULTS

There were 2103 individuals with schizophrenia, 1.25% of the total sample, mean age of 75 years (±1.9) and 61% female. A minority of individuals with schizophrenia, 23%, also had a dementia diagnosis. At 82 years of age (±1.7) and 60% female, 25% of individuals without schizophrenia had a dementia diagnosis; the difference from rate of dementia in individuals with schizophrenia was not statistically significant.

CONCLUSIONS

These findings suggest that further study is needed about the processes that lead to dementia diagnoses in older individuals with schizophrenia.

Niacin Skin Flush Backs-From the Roots of the Test to Nowadays Hope

The niacin skin flush test (NSFT) is a simple method used to assess the content of fatty acids in cell membranes and is a possible indicator of factors hidden behind various outcomes in patients. The purpose of this paper is to determine the potential usefulness of NSFT in mental disorder diagnostics along with the determination of factors that may affect its results. The authors reviewed articles from 1977 onwards, focusing on the history, variety of methodologies, influencing factors, and proposed mechanisms underlying its performance. Research indicated that NSFT could be applicable in early intervention, staging in psychiatry, and the search for new therapeutic methods and drugs based on the mechanisms of NSFT action. The NSFT can contribute to defining an individualized diet for patients and prevent the development of damaging disease effects at an early stage. There is promising evidence for supplementation with polyunsaturated fatty acids, which have a beneficial influence on the metabolic profile and are effective even in the subclinical phase of the disease. NSFT can contribute to the new classification of diseases and a better understanding of certain mental disorders' pathophysiology. However, there is a need to establish a validated method for assessing the NSFT results.

The prognosis of schizophrenia: A systematic review and meta-analysis with meta-regression of 20-year follow-up studies

OBJECTIVE

The aim was to examine the general outcome of schizophrenia after 20 years or more.

METHODS

Using the PRISMA guidelines, we conducted a systematic review and meta-analysis with meta-regression on long-term follow-up studies of schizophrenia up until April 21, 2021. We included prospective studies with at least 20 years of follow-up on patients with a diagnosis of schizophrenia, and the studies had to include face-to-face clinical evaluation. We examined outcome in three nested groups: 'recovery', 'good or better' (including also 'recovery'), and 'moderate or better' (including also 'recovery' and 'good or better'). We used random-effects meta-analysis and meta-regression to examine mean estimates and possible moderators.

RESULTS

We identified 1089 records, which were screened by two independent researchers. 14 prospective studies (1991 patients) published between 1978 and 2020 were found eligible. The studies used a range of different scales and definitions for outcome, and some used the same definitions for different outcomes. To compare outcome across studies, we designed and applied a unified template for outcome definitions and cutoffs, based on earlier studies' recommendations. Our meta-analysis found that 24.2 % had 'recovered' (n = 246, CI: 20.3-28.0 %), 35.5 % had a 'good or better' outcome (n = 766, CI: 26.0-45.0%), and 59.7% had 'moderate or better' outcome (n = 1139, CI: 49.3-70.1 %).

CONCLUSIONS

The results contribute to debunk the myth that schizophrenia inevitably has a deteriorating course. Recovery is certainly possible. Schizophrenia remains, however, a severe and complex mental disorder, exhibiting a limited change in prognosis despite >100 years of research and efforts to improve treatment.

Cariprazine's Potential in Improving Social Dysfunction in Patients With Schizophrenia: A Perspective

Social dysfunction is one of the most debilitating aspects of schizophrenia. Treatment of this complex phenomenon, constituted by negative, cognitive, and affective symptoms, has been difficult with the available pharmacological agents, hence it represents an unmet medical need. Cariprazine, a novel, third-generation antipsychotic with a unique mechanism of action has been proven to sufficiently alleviate negative, cognitive, and affective symptoms of schizophrenia. These characteristics make this compound a valid candidate for addressing social dysfunction too. In this perspective, we argue that cariprazine can be viewed as a "socializing drug" that has the ability to improve the patient's functionality and ultimately their quality of life. Data from animal research, clinical trials, an observational study, and patient cases are provided.

History of ECT in Schizophrenia: From Discovery to Current Use

Eighty years ago, schizophrenia was the first indication for electroconulsive therapy (ECT), and likewise ECT was one of the first treatments used for schizophrenia. This paper presents the history of ECT in the treatment of schizophrenia and its evolution, from it's discovery in the 20th century, which is an example of empiricism with a sequence of "shock" therapies. Following this discovery, the use ECT in schizophrenia has been in expansion during several decades, in a context of lack of efficacy of the treatment in schizophrenia. Then, after World War II and the derivative use of ECT in Germany, the use of ECT has decline during several decades. However, in the last decades, the use of ECT in schizophrenia has reemerged. Indeed, among patients in schizophrenia, rates of resistance to treatment have always been and still are high. In 2017, the concept of "ultra-treatment resistant schizophrenia" was defined when clozapine was tried and failed; and ECT, that had been long since abandoned in the treatment of schizophrenia until recent renewed interest, has emerged especially concerning the add-on of ECT to clozapine. However, ECT remains highly stigmatized and underutilized. This article looks at the history of the practice of ECT in schizophrenia with a historical and clinical approach and makes connections between the history of the treatment and its influence on its current recommendation and practice.