Unitary Psychosis

   (from 1822)

   (See also Psychosis: Emergence.)

   At the biological level, the concept probably originates with Parisian physician Antoine-Laurent-Jessé Bayle (1799–1858) in his work on what was recognized much later as cerebral syphilis (it was his 1822 doctoral dissertation, Research on Mental Illness (Recherches sur les maladies mentales). Bayle did not realize he was dealing with neurosyphilis; he noted only the thickening and adhesiveness of the meninges of the brain caused by some kind of inflammation, or meningitis. He was the first to see brain pathology in those paralysis patients who also had the symptoms of mental illness ("délire monomaniaque" was, for example, the first stage in the progression of symptoms). Bayle said "that chronic arachnitis exists and that it is the cause of a mental derangement with symptoms." Only later was it discovered that these pathological changes in the meninges of the brain ("arachnitis") were the result of neurosyphilis. The discovery of organicity in mental symptoms opened up the possibility that mental illness was just brain disease, and thus that there was really only one cause of madness. Joseph Guislain (1797–1860), professor of psychiatry at the University of Ghent in Belgium, argued in his Treatise on Phrenopathies (Traité sur les phrénopathies, 1833) that there was just one basic form of mental illness, phrenopathy, but that it could take various forms such as mania and melancholia, one clinical picture dissolving into another. This concept influenced a number of German writers, including Heinrich Neumann (1814–1884), then director of a private asylum in Pöpelwitz near Breslau (later professor of psychiatry in Breslau), who proposed in his 1859 Textbook of Psychiatry (Lehrbuch der Psychiatrie) that only one form of insanity existed, which he called simply "madness" (Irresein, later baptized Einheitspsychose), rather than the 48 that Heinroth had postulated. (See German "Romantic" Psychiatry.) Refining the work of earlier authors, who also had believed vaguely in a single process of madness, Neumann said that it went through stages: psychosis (Wahnsinn), marked by delusions and hallucinations; confusion (Verwirrtheit), marked by loosening of associations; dementia, marked by the collapse of mentation (p. 167). If applied not to all psychoses but to today’s schizophrenia, Neumann’s staging has a prescient quality. Meanwhile in France, Jules Falret (1824–1902), the son of Jean-Pierre Falret, was arguing in a major paper in 1866, published in the Annales Médico-psychologiques, that "emotional insanity" (Pinel’s manie sans délire; see Psychosis: Emergence) did not exist and that "in psychological medicine there is no such thing as an isolated lesion of the sentiments or instincts without a simultaneous disturbance of the intellectual faculties" (p. 386). He said that his father had taken this view since 1819. The debate in the nineteenth century reached a provisional end as Wilhelm Griesinger, in the influential second edition of his textbook, The Pathology and Treatment of Mental Illnesses (Die Pathologie und Therapie der psychischen Krankheiten) (1861), took an agnostic position, saying that "a classification of mental illnesses on the basis on their nature, i.e. according to the anatomical brain changes at their core, is at present not possible; rather, because the entire class of mental illnesses is constructed only on the basis of symptoms, we are able to indicate their various forms only on the basis of different complexes of symptoms" (p. 211). As the nosology of Emil Kraepelin came to rule the roost, the notion of a unitary psychosis seemed increasingly implausible.

   In 1958, Karl Menninger revived the concept of "unitary psychosis," at least in a philosophical sense. Drawing upon the psychoanalytic tradition of uninterest in nosology, Menninger said, "Suppose that instead of putting so much emphasis on different kinds of illness we tried to think of all mental illness as being essentially the same in quality, and differing, rather, quantitatively." He wrote in the Bulletin of the Menninger Clinic that "the natural ‘class’ in psychiatry must be either the disturbed individual or all mankind in trouble." This article became the locus classicus for many years of the disbelievers in systematic classification. During the years, the advocates of nosology see-sawed back and forth against the advocates of unitary disease. In 2000 psychiatrist Herbert Y. Meltzer (1921–) of Vanderbilt University School of Medicine argued in Biological Psychiatry that schizophrenia and manic-depressive illness ("bipolar disorder") seemed to have common genetic roots, "provid[ing] additional support for the unitary model of these disorders, the socalled Einheitspsychose of Griesinger" (p. 172).