Acute endogenous psychosis. Part 2

As an in-depth psychopathological study of early dementia, the concept of “schizophrenia” appeared and was recognized. However, the solution to the problem of acute atypical psychosis has not progressed significantly. The clarification of the clinical forms of schizophrenia, made somewhat later by Kraepelin (1913), did not lead to the final solution of the question. As you know, Kraepelin recognized the existence of circular schizophrenia, schizophrenia with a depressive-delusional clinical picture, the possibility of recovery from schizophrenia, its periodic course. For all these reasons, by the end of the 10s and especially in the 20s of our century, the controversy surrounding atypical psychosis intensified.

There were again points of view about the impossibility of reducing many forms of psychosis to one of two endogenous diseases according to Kraepelin’s classification. In France, many psychiatrists again put forward, with minor amendments, the teaching of Magnan on acute polymorphic attacks.

In Germany, by this time, even more attention began to attract direction, whose supporters viewed acute atypical psychosis as a group of endogenous diseases (along with manic-depressive psychosis and schizophrenia). Representatives of the Kleist school in the 1920s proposed a new clinical classification of acute atypical psychosis. This direction has many supporters. Other psychiatrists (Kretchmer, Mautz) have suggested the genetic or constitutional conditionality of the mixed clinical picture of acute atypical psychosis.

A point of view emerged that many of the schizophrenic manifestations of psychosis are “schizophrenic reactions” and their occurrence is associated with the presence of a special form of degenerative background (Popper, 1920), with a schizoid predisposition (Kahn, 1921).

Thus, in the 1920s, the following clinical guidelines for assessing acute atypical psychosis were already determined:

  1. The classical dichotomous direction, which has many supporters at the present time, according to which all atypical psychosis, including acute, can be attributed either to manic-depressive psychosis or to schizophrenia. It may be noted that for supporters of this point of view it was still a controversial question as to which of these two psychoses one should nevertheless refer certain variants of acute atypical psychoses.
  2. The direction according to which acute atypical psychosis should be considered as a special group of endogenous psychosis (Kleist and his school).
  3. The direction that treats atypical psychosis as mixed as a result of combining different constitutional radicals or as reactions when they are especially ready.

In the following decades, up to the 1940s, the central issue regarding acute atypical psychosis remained the issue of their nosological affiliation in numerous discussions on schizophrenia. True, the view was increasingly expressed that it was necessary to consider the possibility of their exogenous conditionality in their nosological assessment. A similar point of view arose after psychiatrists considered “endoform pictures” and began to allow for exogenous mental diseases. Many psychiatrists, supporters of the nosological direction, began to describe various types of acute psychosis, the clinical picture similar to manic-depressive psychosis and schizophrenia. In particular, psychogenic delusional psychosis (acute paranoids, prison psychosis), various catatonic and delusional psychosis in infectious, somatic diseases, etc. were described.

A broader understanding of somatogenic and reactive psychoses led to the “dissolution” of a large number of acute atypical psychoses in them. Nevertheless, the study of acute psychosis from the standpoint of “exogenesis” made it possible to find out a number of important aspects of acute atypical psychosis, in particular, to establish a close connection between the onset of seizures and certain harmful factors.

The literature data on the development of views on acute endogenous psychosis show how difficult they have been for clinical analysis for many decades. As is known, up to the present, these psychoses remain one of the most difficult problems of clinical psychiatry. The extensive literature is devoted to them, in which questions of clinic, psychopathology, systematics, nosological assessment are considered. There are numerous disagreements about these issues. This fact determined the direction of our analysis of the main modern works devoted to the psychoses under consideration. It seems to us important to identify the main sources of still existing difficulties and disagreements regarding the most important clinical aspects of acute endogenous psychosis. Such an analysis of modern literature, together with the historical data, should, in our opinion, facilitate the development of approaches to overcome the difficulties of the clinical evaluation of acute endogenous psychoses.

In determining the scope of the literature to be analyzed, the following provisions were taken into account, arising from the state of clinical psychiatry.

  1. The most clinically clear and generally accepted acute endogenous psychosis are typical manic-depressive psychosis and seizure-like remitting schizophrenia with a fairly pronounced schizophrenic seizure pattern and characteristic schizophrenic personality changes (dissociative defect type). For these two psychoses, the classic differences between manic-depressive psychosis and schizophrenia remain true.
  2. Difficult for clinical evaluation are those acute endogenous psychosis, which are referred to as atypical circular psychosis, schizoaffective psychosis, acute atypical psychosis, recurrent schizophrenia.

In French psychiatry, acute atypical psychosis is currently included in manic-depressive psychosis, in the syndrome of mental confusion (confusion mentale) and in the group of delusional flashes (bouffees delirantes) singled out by Magnan.

In the understanding of French psychiatrists, mental confusion, or “states of confusion,” is a psychopathological syndrome characterized by stupefaction, irregular thinking, disorientation, false recognition (not always), oniric (dreaming) nonsense. Considering the main, determining disorder of confusion (simple or with hallucinatory-delusional phenomena), the syndrome of mental confusion can be understood very broadly.

Along with delirious states (such as delirium tremens), with Korsakov’s psychosis, with various acute infectious and intoxication psychosis, the concept of mental confusion also includes acute delirium (delirium acutum, febrile catatonia), and acute catatonic psychoses (non-febrile) and even psychoses with frustrated mind. leading to organic dementia.

All acute psychoses with catatonic symptoms and disorders of consciousness (including delirium acutum) are practically included in mental confusion as a syndrome of toxic-infectious genesis. Other acute, schizophrenia-like hallucinatory-delusional psychoses are combined by Magnan, the common term “delusional outbreaks”. True, at present (unlike Magnan), this group does not include catatonic psychoses. The delusional outbursts themselves are considered as a syndrome of different etiology, which is not only found in “degenerants”. Clinical and psychopathological description of such psychosis, made by Magnan. remains classical and almost generally accepted. Thus, the main clinical features of these psychoses are: the suddenness of the appearance of delirium (“instant illumination”), polymorphism and instability of delusional stories, massive affect (elevation or decline of mood), clarity of consciousness (at least apparent), and most often a sudden end of an attack. Although relapses are allowed and considered frequent, there is usually no personality change after an attack. The classic clinical forms of these delusional outbreaks are as follows:

  1. Acute fantastic psychoses described by Dupre (1925). We are talking about acute psychosis, the clinical picture of which is determined by the acute fantasy that has arisen, more often such as delusions of grandeur and less often self-incrimination with the nature of immensity.
  2. Acute interpretative psychoses (described by Serieux, Capgras, 1909) and later designated as “acute interpretative states” . These psychoses are delusional syndromes such as acute paranoid with fear and anxiety.
  3. Acute hallucinatory outbreaks and acute hallucinatory psychoses with a predominance of auditory, verbal hallucinations, pseudohallucinations, and impact ideas;
  4. True polymorphic forms, under which the systematization of delusional ideas does not occur.

Many of the acute transient psychoses are considered by French psychiatrists as atypical attacks or equivalents of manic-depressive psychosis. A catatonic equivalent (replacement of one or more affective attacks with catatonic attacks), episodic delusions of exposure, a senestopathic equivalent (an acute senestopathic attack), intermittent hebephrenia, acute paranoids, pseudo-paired melancholia are described; schizoform melancholia, pseudoshizophrenic postpartum psychosis of catatonic structure.

Recently, new terms have appeared and continue to appear to denote individual acute psychosis or whole groups. Baruk distinguishes postpartum hallucinatory delusions and postpartum delusions of persecution. Courchet et al. described acute psychosis in men and called it “transient mania” (according to Krafft-Ebing). According to the authors, this psychosis is a suddenly beginning state of motor excitation or confusion with disorientation, deep anxiety, mutism, without delusions and hallucinations. The psychotic state lasts 2–3 days, followed by a short phase of asthenia, and then recovery occurs. The acute period is completely amnesized. Attacks are not associated with any exogenous factors.

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