Psychosis: Emergence of Concepts

   (See also Folie à Deux; French Chronic Delusional States [from 1909]; Paranoia; Paraphrenia; Positive vs. Negative Symptoms; Schizophrenia: Emergence; Unitary Psychosis.)

   In medicine, psychosis can mean (1) loss of contact with reality, in the form of hallucinations, illusions, and delusions; (2) a synonym for schizophrenia (though one bears in mind there are many psychotic patients, such as those with mania, delirium, or dementia who are not schizophrenic); (3) severe mental illness of any kind; in other words, psychosis on a continuum from neurosis. In fact, for many years every mental illness was referred to as a "psychosis."

   "The history of schizophrenia is actually the history of psychosis in general," wrote Heidelberg psychiatrist and schizophrenia expert Hans Gruhle (1880–1958) in 1932, because "from what was called at the beginning of the discipline of psychiatry . . . insanity, mental derangement, madness, derangement of mind, alienation, maladie mentale, folie . . . pazzia, the exogenous psychoses were increasingly split off, and schizophrenia remained the actual core of insanity." (Gruhle wrote these lines in Oswald Bumke’s [1877–1950] great Handbook of Mental Illnesses [Handbuch der Geisteskrankheiten], vol 5, p. 1.) Although the histories of psychosis and of schizophrenia are highly intertwined, for conceptual simplicity this Dictionary discusses them separately. (See Schizophrenia: Emergence for Kraepelin’s introduction of dementia praecox in 1893 and after.)

   Views at the birth of psychiatry (late eighteenth century). When psychiatry as a discipline was born late in the eighteenth century, there were two schools of thought about the nature of insanity. One school maintained that it was a mental reflection of general body illness. Philippe Pinel, for example, one of the first originators of the concept of the therapeutic asylum, believed that mental illness could arise in such peripheral woes as a spasm of the stomach or a missed period. A second school believed madness to be a poorly understood affliction of the brain itself. Johann Christian Reil (1759–1813), a Leipzig psychiatrist, maintained in 1803 that the brain possessed its own energy—the torpid portions of it having too little, the exalted too much—and that these energy imbalances caused madness (Meditations about the Application of the Psychic Method of Cure to Mental Disorders [Rhapsodien über die Anwendung der psychischen Curmethode auf Geisteszerrüttungen], pp. 47, 49). As for the forms of insanity, most authors agreed there were two, mania and melancholia, the former meaning a general derangement of the mind, the latter a partial (also including the depression of the mood).

   On the whole, these older authors put much greater emphasis on the content of insanity—on so-called associations—than on its form. A patient who had cut his penis off, for example, and had expressed confused religious ideas would be classified as suffering from "religious enthusiasm" rather than psychosis. Of the various components of psychosis, such as delusional thinking, hallucinations, and illusions—all being forms of insanity—differentiation would take place only in the course of the nineteenth century.

   Pinel’s "emotional insanity" (manie sans délire) (1801). In his textbook Traité médico-philosophique sur l’aliénation mentale (1801), Philippe Pinel made a fundamental division that was to run through French, German, and English psychiatry for the rest of the century: distinguishing between madness that does affect intelligence (called "mania with delirium," or manie avec délire), and madness that affects only emotions and drives but not intelligence (emotional insanity), or manie sans délire. In France, virtually every influential psychiatrist except the Falret family picked up this distinction, elaborating it in ever more refined subcategories. The opposing view would be articulated in Germany as "unitary psychosis" (Einheitspsychose), stipulating that it is not possible to have lesions that affect only the drives and emotions but not the intelligence. (In French psychiatry, the term "délire" can mean a number of conditions—especially delusions [see Paranoia], but Pinel used it to mean a disorder of intelligence.) Pinel’s manie sans délire was a condition that shaded lightly into personality disorders as well as madness.

   Esquirol’s monomania (1816, 1838). "The passions of the insane are impetuous," wrote Étienne Esquirol in 1816, "above all in mania and monomania; they are sad in lypemania, in dementia, and in imbecility" ("On Madness" ["De la folie"], p. 14). Esquirol reckoned lypemania to our modern concept of depression. With Esquirol’s monomania, the second important differentiation in the larger notion of insanity takes place (after Pinel’s emotional insanity, or manie sans délire). Esquirol defined monomania generally as the overvaluation of a single idea, as opposed to the excess of all brain functions of mania, with delusions or hallucinations but with intelligence preserved. "We have at Charenton [a Paris mental hospital] a monomaniac, age 30, who is convinced that every night he is led down into the galleries under the Opera" (Maladies mentales, I, p. 214).

   In volume 2 of his On Mental Illness (Des maladies mentales), published in 1838, Esquirol subdivided monomania into three parts—affective, instinctual, and intellectual (p. 2) (on intellectual monomania, see Paranoia). His "instinctual monomania" may be taken as an early description of obsessive-compulsive disorder, obsessive thoughts or compulsive actions. Yet, monomania as a whole represented for Esquirol a kind of partial insanity in which the personality is preserved and the patient’s thinking is not "demented," or chaotic.

   Hallucinations (1817). Esquirol revived the traditional term "hallucinations" in order to describe the symptoms of psychosis (délire); he did so in an essay "On Hallucinations" ("Des hallucinations"): "Someone who has the profound conviction of perceiving a current sensation, while no exterior object apt to excite this sensation is within range of his senses" (Maladies mentales, I, p. 159). He uses the term in its modern sense of perceptions without a real external stimulus. The phenomena of hallucinations as such, however, were long familiar in psychiatric writing (William Cullen had assigned them to the "Morbi Locales"; Sinnestäuschungen is the customary phrase in German; John Haslam of Bethlem Hospital talked in 1809 of "false perception" [Observations on Madness, second ed., p. 28]).

   Differentiating illusions from hallucinations (1832). Esquirol described illusions as a symptom of psychosis: "Illusions, so frequent among the insane, deceive these patients about the qualities, the meaning and the causes of impressions currently being received, and give rise to false judgments about their internal and external sensations; reason does not rectify the error" ("On Illusions" ["Des illlusions"], p. 204). Esquirol employed here the modern sense of the term: distortion or misinterpretation of a real perception. Normal people can commit these misinterpretations as well, without a predisposition to illness, but they are more frequent in people with mental illness.

   Madness is one disease, from 1822.

   See Unitary Psychosis.