H U M A N G E N E T I C S A S A N A P P R O A C H T O T H E C L A S S I F I C A T I O N
O F M E N T A L D I S E A S E S
A N Í B A L S I L V E I R A *
S i n c e 1932, w e h a v e e x p e r i e n c e d s t e a d i l y g r o w i n g d i f f i c u l t y in e n t e r i n g
several m e n t a l diseases p r o p e r l y into B r a z i l i a n c l a s s i f i c a t i o n . A m o n g such
patterns, there is, f o r instance, the " c h r o n i c a l h a l l u c i n a t o r y d e l u s i o n " i s o l a t e d
b y R o x o , w h i c h is p a r a p h r e n i a - l i k e , but not at a l l p a r a p h r e n i a i n the
classical m e a n i n g , and f a r m o r e c o m m o n than this v e r y c o n d i t i o n . L i s t i n g
both entities under the same h e a d i n g , as f o l l o w e d b y our n a t i o n a l system,
resulted in undue o v e r c h a r g e f o r the p r o p e r r u b r i c in B r a z i l i a n statistics.
O t h e r a t y p i c a l patterns such as the " m i x e d p s y c h o s e s "
4, c o u l d not f i n d a
p l a c e in our system and h a d to be f o r c e d into the p l a c e r e s e r v e d f o r o n e
o f the p r i n c i p a l c o n d i t i o n s at p l a y in the g i v e n instance. I f psychiatrists
task w e r e to be construted as o n e o f l a b e l i n g patients, this h a n d i c a p w o u l d
n o t matter, but no r e a s o n a b l e p e r s o n w o u l d foster such v i e w s . T h e
dif-f i c u l t i e s w e r e still m o r e upsetting w h e n w e g o t a c q u a i n t e d w i t h the s e v e r a l
a t y p i c a l e n d o g e n o u s psychoses d e s c r i b e d b y K l e i s t
8. H e r e , the h e r e d o l o g i c a l
f a c t o r s are even m o r e c o m p l e x than i n a n y other m e n t a l diseases q u o t e d
a b o v e . B y r e v i e w i n g the w o r l d literature i n p s y c h i a t r y , o n e b e c o m e s a w a r e
the tremendous, source o f e r r o r that c o m e s f r o m the o v e r l o o k i n g o f K l e i t ' s
set o f psychoses. I n our m i n d , the a p p r e c i a t i o n s o f c l i n i c a l d i a g n o s i s , o f
shock therapies, and m o r e r e c e n t l y the o u t c o m e o f l e u c o t o m y , r e f l e c t h o w
b a d l y n e e d e d is a stable g r o u n d f o r c l i n i c a l d i a g n o s i s o f m e n t a l diseases.
S e v e r a l p a p e r s h a v e shown it f r o m m a n y a n g l e s
3>
6-
12'
18,24. L o o k i n g on
the classifications current in f o r e i g n countries, w e f o u n d the same lack
o f r o o m f o r such a t y p i c a l psychoses o f e n d o g e n o u s p r e d i s p o s i t i o n a l
back-g r o u n d . I n a d d i t i o n , it was a p p a r e n t that n o u n i f o r m and s i m p l e criterion
c o u l d be used b y their authors to a f f o r d a systematic a r r a n g e m e n t f o r the
d i f f e r e n t pntries. E v e r y b o d y f e e l s i m p o s s i b l e , i n d e e d , to o r d i n a t e a l l the
k n o w n psychoses a c c o r d i n g to a n y a n a t o m i c a l standpoint, o r to e t i o l o g i c a l
factors o r e v e n r e g a r d i n g their c l i n i c a l o u t c o m e . A s a result, the m a n y
classifications in h o n o r a b r o a d d i v e r g e f r o m each other o n l y in the measure
that o n e o r another p o i n t o f v i e w is p r e f e r r e d f o r a g i v e n g r o u p o f p s y c h o s e s :
in g e n e r a l , the s o c i a l and e u g e n i c a l aspects o f p s y c h i a t r y a r e l e f t aside in
Presented at the International Congress of Psychiatry ( P a r i s , S e p t e m b e r - 1 5 0 ) .
* Chief of Staff, J u q u e r i State H o s p i t a l , S ã o P a u l o — B r a s i l . L e c t u r e r in
P s y c h i a t r y , U n i v e r s i t y of S ã o P a u l o F a c u l t y of Medicine.
most o f them, since they assemble under one same h e a d i n g psychoses that
b e h a v e in a quite d i f f e r e n t m a n n e r as f a r as h e r e d o l o g i c a l m e a n i n g is
c o n c e r n e d
2 > 1 5 , 1 7 > 1 9 , 2 2.
W i t h such c o n s i d e r a t i o n s in m i n d , w e t r i e d to f i n d out a consistent
c l a s s i f i c a t i o n o f m e n t a l c o n d i t i o n s as w e w e r e c a l l e d to send out suggestions
f o r a r e v i s i o n o f the B r a z i l i a n classification in 1944. T h r e e points set our
r e a s o n i n g : 1 ) the c l i n i c a l o u t c o m e o f psychoses as seen in l o n g i t u d i o n a l
section, so to s p e a k ; 2 ) the g e n e r a l features o f the psychoses as a g r o u p ,
as seen in the d a i l y p r a c t i c e , that is, f r o m the p r a c t i c i o n e r ' s p o i n t o f v i e w ;
3 ) the h e r e d i t a r y s i g n i f i c a n c e o f the i n d i v i d u a l psychoses, that is, their
i m p l i c a t i o n f o r the descendants o f the patients. T h e latter data w e r e to be
d e r i v e d f r o m the a v a i l a b l e tables o f " e m p i r i c a l h e r e d o p r o g n o s i s "
2 > 5 > 7'
1 4'
2 0and p r i n c i p a l l y f r o m the h e r e d o l o g i c a l researches c a r r i e d out
accord-i n g to the p r e c accord-i s accord-i o n m e t h o d f o r d accord-i f f e r e n t accord-i a t accord-i o n o f patterns, e m p l o y e d by
K l e i s t and c o - w o r k e r s
3- * •
9-
10'>
1 T-
2 1.
C o m b i n i n g these v i e w s and d i v e r g i n g in m a n y points f r o m the p r o p o s e d
r e v i s i o n , so to a p p r o x i m a t e it to the g e n e r a l patterns o f classification f o l l o w
-e d in our n a t i o n a l gyst-ematics, w -e a r r i v -e d at a t-entativ-e substitut-e
2 2, in w h i c h
w e tried to a v o i d doctrinal e l a b o r a t i o n s , l i m i t i n g ourselves to dispose its
h e a d i n g s in r e g a r d to " e u g e n i c p r o f i l a x i s " . S o m e y e a r s later, in 1948, it
was p o s s i b l e to set farther the c o m b i n a t i o n o f e u g e n i c a l and d y n a m i c
cri-teria, since w e h a d the o r i g i n a l B r a z i l i a n classification f o r starting p o i n t .
T h i s e n a b l e d us to i n c l u d e a f e w mental c o n d i t i o n s not c o n s i d e r e d in other
systems and at the same t i m e to separate in a m o r e definite manner the
e n d o g e n o u s illnesses and the casual patterns s i m u l a t i n g them. T h e psychoses,
2 4 in n u m b e r , entered there into 5 m a j o r g r o u p s , a r r a n g e d a c c o r d i n g to the
intensity o f e n d o g e n o u s taint i m p l i e d b y them
2 3. H o w e v e r , as w e m a n a g e d
to ascertain t h r o u g h h o s p i t a l practice the p r o p e r o r d e r o f the i n d i v i d u a l
h e a d i n g s , s o m e changes o f p o s i t i o n w e r e f o u n d necessary, yet k e e p i n g e v e r y
item under its p r e v i o u s main g r o u p . Such r e a r r a n g e m e n t is presented in
this p a p e r ( t a b l e I ) .
n o t i c e d at first sight and has to be l o o k e d f o r , often in terms o f a b n o r m a l
p e r s o n a l i t y traits o n l y ; 5 ) D e f e c t i v e m e n t a l patterns, in w h i c h the genetic
f a c t o r reflects on the sensitivity o f c e r e b r a l systems to injuries and is
r e s p o n s i b l e f o r their functional d e c a y as w e l l as f o r their s e l e c t i v e a n a t o m i c a l
d e t e r i o r a t i o n .
O n the other hand, t r y i n g to check the a b o v e g r o u p s against the e n v i r o n
-mental o r the s o m a t o g e n i c factors at p l a y , w e m a y f i n d that these latter
decrease in p r e c i s i o n or in effectiveness as w e p r o c e e d f r o m the e x t r e m e
units t o w a r d the central o n e , h e r e c a l l e d I I I , w h i c h represents the c l i m a x
of h e r e d o l o g i c a l trends. T h u s , the toxiinfectious diseases w i t h mental i l l
-ness as a g r o u p , show m o r e d e f i n i t e mechanisms o f action than the psychoses
b y i n t o x i c a t i o n listed under I I . A b o u t in the same w a y , factors that
pre-cipitate the mental patterns shift f r o m p r e d i s p o s i t i o n a l , p s y c h o l o g i c a l and
situational in g r o u p I V , to o v e r t l y structural in the last g r o u p , here in
terms o f b r a i n lesions f o c a l and then d i f f u s e . U s i n g the same c r i t e r i o n
f o r r a n k i n g o f the differents patterns w i t h i n each m a j o r g r o u p , the o r d e r
of the f o r m e r e m e r g e s n a t u r a l l y . F o r instance, G e n e r a l P a r a l y s i s and t o x i
-i n f e c l -i o u s psychoses -in general should represent the t w o e x t r e m e s o f g r o u p
I , the latter b e i n g c l o s e to psychosis b y accidental i n t o x i c a t i o n in the
second g r o u p ; within unit V , systemic a b i o t r o p h i c diseases as A l z h e i m e r ' s
and P i c k ' s w e r e to be a b o u n d o p p o s i t e to mental d e f i c i t b y g e n e r a l
e n c e p h a l o p a t h y . A s f o r the endogenous- sets, constitutional and m a r g i n a l ,
w e h a v e a c o m p a r a b l e disposition f o r the i n d i v i d u a l c o n d i t i o n s : f r o m
epi-l e p s y to p a r a n o i a there is a curve w i t h its a c m e in s c h i z o p h r e n i a as the
e n d o g e n o u s c h a r g e shows itself m o r e consistent a n d o b v i o u s and the
ab-n o r m a l c o ab-n d i t i o ab-n m o r e p e r m a ab-n e ab-n t ; iab-n a d d i t i o ab-n , o l i g o p h r e ab-n i a represeab-ntiab-ng
a d i f f e r e n t k i n d o f h e r e d o l o g i c a l transmission and m i x e d psychoses
point-i n g to the point-interactpoint-ion o f m o r e than one h e r e d o l o g point-i c a l c point-i r c l e , f a l l near to
the f o u r t h m a i n g r o u p . I n this o n e a l l o f the entries, listed under 14
to 2 0 , i n v o l v e the inheritance o f a b n o r m a l trends as a b a c k g r o u n d : f o r
the first t y p e w e h a v e the c o m b i n a t i o n o f d i v e r g i n g m o r b i d circles and
f o r the next t w o the a p p e a r a n c e r e s p e c t i v e l y o f a b n o r m a l but consistent
set o f traits and o f i s o l a t e d d y s g e n i c t r e n d s ; there c o m e next t w o mental
c o n d i t i o n s i n w h i c h u n d e r l y i n g trends are b r o u g h t to l i g h t b y p s y c h o g e n i c
or situational f a c t o r s , and f o l l o w i n g t w o further ones i n w h i c h the
interven-i n g m o m e n t interven-is m o r e structural, c e r e b r a l interven-in character.
I n the a b o v e c l i n i c a l c o n d i t i o n s , it is easy to see, the e f f i c i e n c y o f
therapeutic measures runs in p a r a l l e l w i t h the e x o g e n o u s f a c t o r s , w i t h the
e x c e p t i o n o f neurotic and p s y c h o g e n i c c o n d i t i o n s as w e l l as the t y p i c a l
and m a r g i n a l " f u n c t i o n a l " psychoses, r e c o v e r i e s in these latter ones b e i n g
o n l y transitory o r phasic.
m a y s u p p o r t o u r h o p e f o r a r a t i o n a l c l a s s i f i c a t i o n o f m e n t a l diseases in
t e r m s o f a " n a t u r a l s e r i e s " in the l i g h t o f h u m a n g e n e t i c s .
T A B L E I
I — Psyshoses with toxiinfectious diseases: 1 — D i f f u s e syphilitic m e n i n g o -encephalitis ( G . P . ) ; 2 — N e u r o - s y p h i l i s in g e n e r a l ; 3 —• E p i d e m i c n e u r a x i t i s ;
4 — Psychoses w i t h infectious diseases, in general.
I I — Psychoses with accidental intoxications: 5 — Psychosis d u e to accidental intoxication; 6 — Psychosis d u e to auto-intoxication ( e n d o c r i n e o r m e t a b o l i c ) .
I I I — Constitutional endogenous psychoses: 7 — E p i l e p s y p r o p e r ; 8 — M a niacdepressive psychosis; 9 — Schizophrenia; 10 — P a r a p h r e n i a ; 11 — P a r a n o i a ; 12 — O l i g o p h r e n i a p r o p e r ( e n d o g e n o u s ) ; 13 — M i x e d a n d combined p s y -choses.
I V — Marginal endogenous states: 14 — Autocthonous atypical degenerative psychosis ( K l e i s t ) ; 15 — P s y c h o p a t h i c p e r s o n a l i t y ; 16 — D r u g a d d i c t i o n ; 17 — N e u r o s i s ; 18 — R e a c t i v e psychosis; 19 — S y m p t o m a t i c seizures; 20 — Chronic hallucinatory delusion.
V — Defective states by local or abiotrophic brain lesions: 21 — Alzheimer's a n d Pick's diseases; c e r e b r a l arteriosclerosis: 22 — Senile dementia p r o p e r ; 23 — B r a i n focal lesions in g e n e r a l ; 24 — M e n t a l deficit b y encephalopathy, not en-d o g e n o u s .
S U M M A R Y
I f w e t r y to a r r a n g e the m a n y patterns o f m e n t a l disease as r e g a r d s
d i s p o s e d as a " n a t u r a l s e r i e s " . I n our tentative o n e , w h i c h c o m b i n e s
e u g e n i c and d y n a m i c criteria c h i e f l y , w e t r i e d to assemble 2 4 separate
c l i n i c a l c o n d i t i o n s into 5 m a j o r g r o u p s : I — Psychoses with toxi-infectious
diseases ( 4 e n t r i e s ) ; I I — Psychoses with accidental intoxications ( 2
e n t r i e s ) ; I I I •
— • Constitutional endogenous psychoses ( 7 e n t r i e s ) ; I V —
Marginal endogenous states ( 7 e n t r i e s ) ; V — Defective states by local
or abiotrophic brain lesions ( 4 e n t r i e s ) . A m o n g the c o n d i t i o n s listed under
I V are K l e i s t ' s m a r g i n a l or " d e g e n e r a t i v e " psychoses, w h i c h are frequent
i n d e e d in p s y c h i a t r i c p r a c t i c e , so to r e q u i r e their c o n s i d e r a t i o n .
R E S U M E
Si 1'on o r d o n n e les diverses f o r m e s de m a l a d i e s m e n t a l e d'apres les
facteurs h ι r ι d o l o g i q u e s sousjacents i l en resulte une v r a i e " s ι r i e n a t u r e l l e " .
N o u s avons essayι une classification c o m b i n a n t surtout les caracteres
eu-g ι n i q u e et d y n a m i q u e , y faisant rentrer 24 conditions c l i n i q u e s diverses,
rangιes dans 5 g r o u p e s p r i n c i p a u x : I — Psychoses par maladie
toxi-in-fectieuse ( 4 r u b r i q u e s ) ; I I — Psychoses par intoxication accidentale ( 2
r u b r i q u e s ) ; I I I — Psychoses endogènes constitutionnelles ( 7 r u b r i q u e s ) ;
I V — États endogènes marginaux ( 7 r u b r i q u e s ) ; V — Élats déficitaires
par lésions cérébrales en foyer ou abiotrophiques ( 4 r u b r i q u e s ) . P a r m i
les c o n d i t i o n s sous I V se trouvent les psychoses m a r g i n a l e s " d ι g ι n e r a t i v e s "
de K l e i s t , dont la f r e q u e n c e dans la p r a t i q u e p s y c h i a t r i q u e j o u r n a l i θ r e
leur assure une p l a c e i n d i v i d u e l l e dans l e classement.
R E S U M O
D i s p o n d o as diferentes f o r m a s de doenηa mental de a c o r d o c o m os
fatores h e r e d o l σ g i c o s subjacentes obtιm-se uma v e r d a d e i r a " s ι r i e n a t u r a l " .
A classificaηγo que p r o c u r a m o s estabelecer c o m b i n a os c r i t ι r i o s e u g κ n i c o
e d i n β m i c o p r i n c i p a l m e n t e e consta de 2 4 q u a d r o s c l ν n i c o s distintos,
reu-nidos e m 5 g r u p o s f u n d a m e n t a i s : I — Psicoses de origem infecciosa
pre-dominante ( 4 r u b r i c a s ) ; I I — Psicoses de origem tóxica prepre-dominante ( 2
r u b r i c a s ) ; I I I — Psicoses endógenas constitucionais ( 7 r u b r i c a s ) ; I V —
Quadros endógenos marginais ( 7 r u b r i c a s ) ; V — Quadros deficitários por
lesões focais ou abiotróficas do cérebro ( 4 r u b r i c a s ) . E n t r e as c o n d i η υ e s
clνnicas d o g r u p o I V encontram-se as psicoses m a r g i n a i s " d e g e n e r a t i v a s "
de K l e i s t , cuja f r e q ٧ κ n c i a na p s i q u i a t r i a cotidiana lhes assegura l u g a r
in-d i v i in-d u a l i z a in-d o na. c l a s s i f i c a η γ o .
R E F E R E N C E S
1. B a r a h o n a F e r n a n d e s , H . J . — H e r e d i t a r i e d a d e e p r o f i l a x i a eugκnica das
doenηas mentais. I m p r . M é d . ( L i s b o a ) , 7:1-25, 1941.
2. C o n r a d , K . — E r b a n l a g e u n d Epilepsie. Ztschr. f. N e u r o l . , 159:521, 1937.
3. F ٧ n f g e l d , E . — D i e Motilitãtspsychosen u n d V e r w i r r t h e i t e n . K a r g e r , B e r
4. G a u p p , K . u . M a u z , F . •— Krankheitseinheit u n d Mischpsychosen. Ztschr. f. N e u r o l . , 101:1-44, 1926.
5. G e r u m , K . — B e i t r a g zur F r a g e d e r E r b b i o l o g i e der genuinen E p i l e p s i e , der epileptoiden E r k r a n k u n g e n u n d d e r epileptoiden Psychopathien. Ztschr. f. N e u r o l . , 115:319-422, 1928.
6. H o c h , P . a . R a c h l i n , H . L . — A n evaluation of manic-depressive psychosis in the light of f o l l o w - u p studies. A m e r . J. Psychiat., 97:831, 1941.
7. K a l l m a n n , F . J . — T h e genetics of psychoses. A n analysis of 1,232 t w i n index families. R e p o r t C o n g r . I n t e r n a t . Psychiatrie ( P a r i s ) , 6:1-40, 1950. 8. Kleist, K . — a) ٢ b e r zykloide, p a r a n o i d e u n d epileptoide Psychosen u n d
iiber die F r a g e d e r D « g e n e r a t i o n s p s y c h o s e n . Schweiz. Arcii. f. N e u r o l , u. Psychiat., 23:3-37, 1928. 6 ) F o r t s c h r . d. Psvchiatrie ( F r a n k f u r t ) K r a m e r , 1947.
9. Kleist, K . u . D r i e s t , W . — D i e K a t a t o n i e n a u f G r u n d katamnestieher U n -tersuchungen ( I T e i l ) . Ztschr. f. N e u r o l . , 157:479-556, 1937.
10. K l e i s t , K . , L e o n h a r d , K . u . S c h w a b , H . — D i e K a t a t o n i e n auf G r u n d k a -tamnestieher U n t e r s u c h u n g e n (111 T e i l ) Ztschr. f. N e u r o l . , 168:535-586, 1940.
11. Kleist, K . u . S c h w a b , H . — D i e v e r w o r r e n e n Schizophrenien auf G r u n d katamnestiseher U n t e r s u c h u n g e n . A r c h . f. Psychiat. u. Ztschr. f. N e u r o l . , 184: 28-79', 1950.
12. L a n g f e l d t , G . — Z u r F r a g e d e r spontanen Remissionen d e r schizophrenifor-men Psychosen mit b e s o n d e r e r Berichtsichtigung der F r a g e nach der D a u e r dieser Remissionem. Ztschr. f. N e u r o l . , 164:494-500, 1939.
13. L e o n h a r d , K . — A t y p i s c h e endogene Psychosen im L i c h t e d e r F a m i l i e n f o r -schung. Ztschr. f. N e u r o l . , 149:520, 1934.
14. L u x e n b u r g e r , H . — Eugenische P r o p h y l a x e . In B l e u l e r , E . — L e h r b u c h d e r Psychiatrie, S p r i n g e r , B e r l i n , 1937.
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