Comment on Lara Rzesnitzek (2013) “Early Psychosis” as a mirror of biologist controversies in post-war German, Anglo-Saxon, and Soviet Psychiatry

A mental illness with severe disturbances of subjective experiences and behavior with a progressive course, due to the onset of cognitive deterioration during the second and third decade of life, was described more than a century ago as dementia praecox (Kraepelin, 1896). In 1911 the diversity of existing marked symptoms led to the suggestion of a group of mental disorders, summarized as “Dementia praecox or group of schizophrenias” (Bleuler, 1911). Under the term schizophrenia various core symptoms of the diagnosis and/or of the disorder were defined, among others mainly: basic and secondary symptoms (Bleuler, 1911), first and second rank symptoms (Schneider, 1950), positive and negative symptoms (Andreasen, 1982). Sometimes the significance of the affective and intentional symptoms prevailed, at other times the cognitive disturbances were seen as the central phenomena, thus, e.g., in reframing schizophrenia as a “cognitive illness” (Kahn and Keefe, 2013). For more than 100 years the enigma of schizophrenia has been under debate (Häfner, 2005). Particularly the nature of “basic” (Bleuler, 1911) or “negative” symptoms (Andreasen, 1982) is unclear: are these psychopathological phenomena—special cognitive disturbances, blunted affect sometimes difficult to differentiate from depressive disturbances (Häfner et al., 2013), and intentional disturbances—core symptoms of the disease or risk factors or consequences of the disease—or a mixture of all of them? Lara Rzesnitzek (2013) in her informative and readable review recalls the early discussion on the nosological status of “early psychosis”: are its seemingly unspecific but in its entirety rather specific psychopathological phenomena before the manifestation of unequivocally psychotic symptoms dispositional and stable risk factors or initial symptoms of a gradually developing schizophrenia? Today’s psychiatrists may wonder about the categorical black-or-white thinking of former conceptualists due to the currently dominating, more multiconditional concept, i.e., a specified bio-psychosocial model: developmental interactions between genetically conveyed sensitivity toward a distinct social context (and perhaps perinatal brain lesions as well) may form a disposition of vulnerability for critical life events, e.g., hormonal changes or social stress during adolescence (Zubin and Spring, 1977; Häfner, 2002; Haddad and Meyer-Lindenberg, 2012). “Early psychosis” today is subject to empirical longterm investigations on transition rates from bland symptoms to full blown psychoses, on contextual conditions and consequences, such as the Mannheim ABC-Study (Häfner et al., 2013), and on treatment. In view of this I will comment on some ethical implications of “early psychosis,” irrespectively whether the symptoms indicate risk factors with predictive value or a beginning psychosis, because symptoms will be treated only if they intensify over time into functional or social handicaps. Due to the blandness of symptoms and their sluggish manifestation the diagnosis of “early schizophrenia” is difficult. This implies a particular responsibility of the diagnostician with regard to various aspects: