In the clinical evaluation of acute atypical psychosis, French psychiatrists do not raise the question of their relationship to schizophrenia. This is explained by the fact that schizophrenia is regarded by them only as a purely psychopathological concept. This is “chronic discordant psychosis”, the essence of which lies in a peculiar personality change, “total modification of human existence”, etc. (Follin, 1958; Ey, 1958). Discordance and autism are considered to be determining disorders (Ey adds nonsense). Clinically, schizophrenia includes 4 nuclear forms according to Kraepelin’s classification and some cases with a sluggish course (Eue et al., 1967).
Understanding schizophrenia as a purely psychopathological phenomenon, the content of which is personality change, it is assumed that a variety of illnesses can cause schizophrenia, including acute delusions and confusion. Acute psychoses (“syndromes”) are considered nosologically free, mobile. So Laboucarie and Barres (1959) with the clinical and follow-up study of 400 patients with acute psychosis (follow-up period 5–20 years) obtained the following results: in 100 patients, mental confusion or manic-depressive psychosis was determined after analysis of the first attack. The remaining 300 patients were divided into two groups according to the characteristics of the clinical picture of the first attack: a) with the state of the polymorphic structure (170 patients) and b) with acute depersonalization syndromes (130 patients).
For the states of the polymorphic structure, the authors consider the characteristic: a sudden onset without prodrome (as a rule, after psychogeny); global disorder of consciousness of the type of true oneiroid with fluctuations of its degree; affective disorders (most often of the type of purely manic or with elements of disturbing melancholia); polymorphic nonsense without systematization.
The first attack ended in complete remission after a few weeks or (less) months. The further course of the disease according to the follow-up was estimated as follows: in 30% of cases, remission after the first attack was stable, and there was no recurrence of the disease; 50% of patients had relapses, either with the same picture of the attack, or in the form of phases of manic-depressive psychosis. In 15% of patients, the disease took the form of chronically current schizophrenia.In conditions of acute depersonalization, the first attack was almost always preceded by a prodromal period, such as neurotic changes with elements of autism.
Psychosis often began spontaneously, and, if psychogeny occurred, it was rather a prolonged conflict situation in the family. The attack itself was characterized by ambivalence, an abundance of senesthopathic and catatonic symptoms against the background of unexpressed consciousness disorder (such as a reduced one-neuroid). The attack lasted from 3 months to 1 year, regardless of treatment.
The follow-up history of this group of patients revealed the following course options: “recovery” after the first attack in 20% of patients; rapid transition to classical schizophrenia in 30% – (the disease has taken a particularly malignant course); 50% of patients had relapses. In some of these patients, recovery from the defect sometimes occurred after many attacks. In other patients, after many years of almost complete recovery, there were bouts of melancholia, which are easily treatable. In other cases, relapses retained a schizophrenic nature, including the type of periodic catatonia.
The schizophrenic or affective structure of seizures depends, according to the authors, most of all on age. It is assumed that, despite the apparent schizophrenic structure of the first attacks (at a young age), the course of the disease in later periods proceeds very often in the manner of manic-depressive psychosis.Lacassin (1959), on the basis of a study of 180 patients with acute schizophrenia (the disease was at least 5 years old), concluded that the clinical picture of the initial period does not have the characteristic features that allow one to predict the course and even make a diagnosis. Regarding the psychopathological structure of these psychoses, Lacassin joins Ey’s point of view, considering them to be a manifestation of a particular level of consciousness destructuring, namely the oneiric level (see below).
Of the post-war works of French authors, the most significant in volume, depth of analysis and original views are the works of Ey. Most fully the views of this author are set forth in a large monograph on the structure of acute psychosis (1954). In this work, Eu expresses a special point of view on the question of the psychopathological structure and pathogenesis of all acute psychoses (manic-depressive psychosis, symptomatic affective psychoses, acute toxico-infectious, organic, epileptic psychoses, delusional outbreaks).Staying in terms of the clinical division of the true traditions of French psychiatry, Ey tries to explain the existence of many clinical options from the perspective of a special understanding of the whole of psychopathology.
In terms of psychopathology, in which, according to the author, the classification of psychosis is only possible, all psychotic states are divided into two groups: acute psychosis, which is caused by a pathology of consciousness (especially understood by him), and psychosis associated with personality pathology. The author refers to the first group:
1) manic and depressive seizures (endogenous or symptomatic, mono- or bipolar),
2) acute delusional and hallucinatory outbreaks and one-iroic states (also regardless of their etiology)
3) confused-onyric psychosis (delirious and amental structure).
Three groups of acute psychosis represent, in Ey’s view, the clinical expression of the three levels of consciousness destructuring. In the first degree of consciousness destruc- tion, a manic and depressive state arises; with a deeper disturbance of consciousness, acute delusional and hallucinatory flashes and oneiric states arise, and finally, the third, deepest degree of consciousness destruc- tion corresponds to psychosis, designated as exogenous delirium, exogenous confusion, amentia, etc. This understanding and classification of acute psychosis follows from general theoretical positions of the author, defending the need for an application to the psychiatry of the Jackson concept.
Ey understands consciousness as a form (“layer”) of psychic life, which “organizes in the field of the presenting present” sensually experienced at the moment (including data of perception, part of past experience and ideas about the future). In the “field of consciousness” at each moment the subjective and objective are presented, which are ordered by consciousness. The main content of consciousness is ordered sensory experiences. Hence the concepts of “phenomenal field”, “scene”. This field has a dynamic structure and organization. Consciousness has its own structure, reflecting the stages of evolution during life. The first, least profound degree of impairment of consciousness is “temporarily ethical destruction”.
Clinically, this is expressed in manic and depressive syndrome.In the manic state, only the direction of the stream of consciousness, its “ethical-temporal” orientation, changes. The consciousness of a maniacal patient is a “propulsion movement”, thanks to which the subject “breaks away from the forms of the present and eliminates them as rules of behavior”. Subjectively, this disorder is experienced by the patients as “endless striving forward”, as “celebration”, in which “all impulses of mastering the world are satisfied”, and clinically it is ecstasy, enchantment, etc. With melancholy, the negative structure consists, on the contrary, “to stop and retreat in the face of the requirements of the present. ” The positive structure of melancholia is expressed in tragedy or anxiety, in which all sorts of fears are actualized.
Both the manic and the depressive patient are characterized by “impossibility to balance with the present” and to keep in it. This ability, according to the author, is part of the functions of consciousness and is upset in the first place.With the next, deeper level of consciousness destruc- tion, except for a temporary ethical disorder, that is, a violation of the direction and purpose of consciousness, the sensory representation in the field of consciousness of reality itself is also disturbed.
This level of destructiveness corresponds to “delusional flashes”, epileptic twilight states, intoxication hallucinatory-delusional psychosis without confusion, oneiric syndrome, etc. With such a disorder of consciousness, there is a destruc- tion of the perception itself, which leads to a change in the temporal-spatial structure of the relationship between “I” and “peace”.
With a mild degree of disturbance of the temporal-spatial “layer” of consciousness, a disorder in the perception of the body arises, that is, the “bodily space” is upset (depersonalization, violations of the body pattern and senestopathy). If the violation is more profound, depersonalization reaches the depth of the “thinking person” and this is experienced by the patient as penetration, seizure, parasitism in thinking (mental automatisms and hallucinations, “experiencing hallucinatory splitting or acute states of mental automatism”).
With a somewhat deeper destruc- tion, the “fantastic encompasses the whole consciousness”, a “complete overturn of the space” sets in and a one-way state arises.Thus, Ey divides this second level of consciousness destruction into several degrees, with each of which connects groups of symptoms.When, finally, the destruction of consciousness encompasses “the ability to create a field,” the ability to “present,” there is a syndrome of mental confusion (amentia), in which clinically there is the impossibility of differentiating mental processes, deep obscuration, disorientation in space and space, and the world almost completely ceases. ” introduce myself. ”
According to Ey, each subsequent level of consciousness destruc- tion includes the violations of the previous level and therefore the clinic has affective disorders, for example, in the oneiric state, and affective disorders and symptoms inherent in the oneiric state in the amential state.In terms of clinical classification, Ey does not deviate from the traditional clinical division characteristic of French psychiatry, and proposes only with regard to psychoses of the “second level of destruction”, i.e. hallucinatory-oneiric, to distinguish two thematic modalities: the theme of happiness (ecstasy) and the theme of unhappiness (disaster, torment).
The concept of Ey represents, therefore, an attempt to more modernized the rationale for the traditional division of acute psychosis into large syndromes.Интересной является попытка квалифицировать