Psychopharmacology and the Classification of Functional Psychoses 

By Thomas A. Ban and Bertalan Pethö

Classification and Clinical Psychopharmacology

Research Criteria

In addition to the diagnostic criteria of ICD-9 and DSM-III, introduced primarily for clinical use, several other diagnostic criteria relevant to the population of functional psychoses, were developed primarily for research purposes. Among them the most frequently employed are the St. Louis Criteria (Feighner et al., 1972), the Research Diagnostic Criteria (Spitzer, Endicott and Robins, 1978a and b), Taylor and Abrams Criteria (Taylor and Abrams, 1978; Taylor, Redfield and Abrams, 1981) and the Vienna Research Criteria (Berner and Katschnig, 1983).

The St. Louis criteria for the diagnosis of schizophrenia are based on methodological considerations relevant to improvement of diagnostic validity put forward by Robins and Guze (1970); and the St. Louis criteria for the diagnosis of affective disorder are based on the concepts of "primary" and "secondary" affective disorders developed by Robins et al. (1972). They are frequently referred to as Feighner's criteria because they were first presented in an operationalized format in a paper published by Feighner et al. (1972). The criteria for schizophrenia consist of psychopathological symptoms and other manifestations. Because the St. Louis criteria for schizophrenia were designed to diagnose "poor-prognosis" patients and to separate them from "good-prognosis" patients, they represent a restricted view of schizophrenia that excludes many patients. The same applies to the St. Louis criteria for affective disorders, i.e., primary depression, secondary depression and mania. In spite of this, until the introduction of the DSM-III the St. Louis criteria were probably one of the most extensively employed research diagnostic criteria in the testing of therapeutic efficacy of antipsychotic and antidepressant drugs (Appendix V, Table I).

The Research Diagnostic Criteria (RDC) is an elaboration, expansion and modification of the St. Louis criteria by Spitzer, Endicott and Robins (1978a and b). It was developed as part of a collaborative project on the psycho- biology of depressive disorders sponsored by the Clinical Research Branch of the National Institute of Mental Health of the United States (Maas et al., 1980). As a result of the modifications the RDC is considerably more inclusive than the St. Louis criteria. Although it allows only for a narrow definition of different disorders it can accommodate most patients. Furthermore by subtyping schizophrenic psychoses on the basis of its course and manifest psychopathological symptoms (phenomenology) and by subdividing major affective disorders into a number of different types it allows for the testing of many hypotheses relevant to schizophrenic and affective illnesses (Appendix V, Table II).

Considerably different than the St. Louis criteria and the RDC are Taylor and Abrams' criteria for schizophrenia, mania and endogenous depression (Abrams, Taylor and Gaztanga, 1974; Taylor and Abrams, 1978; Taylor, Gaztanga and Abrams, 1974; Taylor, Redfield and Abrams, 1981). These criteria developed in the course of a dialogue with the St. Louis group (Taylor and Abrams, 1975) and are more in keeping with the Kraepelinian and Bleulerian tradition than the St. Louis criteria. Taylor and Abrams' criteria of mania and endogenous depression are derived from Slater and Roth's (1969) classical descriptions. Although they are essentially pragmatic and empirical, Taylor and Abrams' criteria have been included in heuristic studies comparing different diagnostic systems (Appendix V, Table III).

The Vienna Research Criteria (VRC) for schizophrenic psychoses, referred to as the endogenomorphic-schizophrenic axial syndrome, and affective disorders, referred to as endogenomorphic-affective axial syndromes superficially resemble Taylor and Abrams' criteria. Its development can be traced to Berner's (1965, 1969) follow up study on paranoiac patients; and the recognition that a proportion of these patients suffer from a schizophrenic or an affective (referred to as cyclothymic) disorder. With the syndromes derived from the initial psychopathological symptom profiles a catamnestic study was designed. The purpose of this study was to test the hypothesis that paranoiac patients can be assigned to one of the two diagnoses on the basis of operationally defined criteria at the time of their first (index) admission (Muller, 1981). The operationally defined criteria were referred to as "axial syndromes," a term first used by Hoche (1912). The adjective "endogenomorphic" was added for distinguishing axial syndromes from definitive diagnoses. The VRC consists of six endogenomorphic axial syndromes, one schizophrenic and five affective.

In the formulation of the six axial syndromes, Janzarik's (1948, 1959) concept of "structural dynamic coherency" has played an important role. Within this frame of reference Schneider's (1950, 1959) first rank symptoms (Mellor, 1982) and some of Bleuler's (1911, 1950) fundamental symptoms, such as ambivalence, depersonalization and derealization are not considered to be of diagnostic significance. Other fundamental symptoms such as formal thought disorder, affective blunting and cryptic neologisms, are considered to be nonspecific. However, they remain acceptable criteria because diagnostically there are either schizophrenic or organic (but definitely not affective) in origin. Taking all these into consideration it is not surprising that the endogenomorphic axial schizophrenic syndrome has the narrowest concept of schizophrenia among all research diagnostic criteria.

The five endogenomorphic axial affective syndromes are referred to as depressive, manic, dysphoric, unstable mixed and stable mixed. Common characteristics of these axial syndromes are the disturbance of biorhythm manifest in the diurnal variation of symptoms and sleep disturbance. Differential characteristics are based on the different types of dynamic derailments described by Janzarik (1948, 1959) and Berner (1969), e.g., dynamic expansion (seen in the manic axial syndrome), dynamic restriction (seen in the depressive axial syndrome), dynamic instability characterized by rapid fluctuation or swings between the first two (seen in the unstable mixed axial syndrome). It remains to be seen whether the diagnostic groups, which are based on this highly sophisticated theoretical approach are biologically more homogenous than the diagnostic groups based on other diagnostic criteria for research.