How far is psychopathology still meaningful for the treatment of schizophrenia?

Abstract

The paper gives reasons for the view that psychopathology has to be not only the fundamental method for clinical psychiatry, but also an essential prerequisite for a rational therapy of schizophrenia and related disorders. Because schizophrenic patients present very different types of psychopathological cross-sectional syndromes, the choice of a distinct neuroleptic or antidepressant compound and their dosage has to be guided along the psychopathological target syndrome. The clinical-therapeutical effects of neuroleptics and antidepressants are above all symptom- (Freyhan) or syndrome-directed. The differentiation of positive and negative symptoms, acute and chronic or residual schizophrenia, or of the prodromal symptoms according to contemporary approaches seems to be not sufficient for the early detection of psychopathological predictors of an impending psychosis and the special indication and choice of a distinct drug and dosing strategy. This is valid for maintenance treatment of patients in remission, for early intervention in the prodromal stages before the first and later psychotic episodes and in preventing relapses. Relapse rates can be reduced by a low dose maintenance therapy with basic symptom oriented early adaptation of the dosage in the prodromes before psychotic remanifestations. Some presuppositions of an effective psychopharmacological and psychological therapy in view of clinical psychopathology (K. Schneider) and the "phenomenological attitude" (K. Jaspers) are outlined. A necessary condition for the secondary as well as for the primary prevention of psychotic episodes is the detailed knowledge of the interindividual different dynamic and cognitive basic symptoms, defined in the Bonn Scale BSABS, that are experiential in kind and not identical with the negative and behavioral "Prodromal and Residual Symptoms" of DSM and ICD-10. The early detection and preventive intervention of schizophrenic psychoses is most likely possible by means of a subtle, descriptive-analytical phenomenology and psychopathology. Also "chronic" patients beyond acute psychoses, e. g. those with persisting pure residues, characterized not by true negative, but by basic symptoms, often respond to distinct atypical neuroleptics and/or antidepressants. The knowledge of the prodromal symptoms and the coping strategies, frequently developed by the patients themselves, is an essential component of a basic symptom oriented psychoeducational concept.