Moral insanity

   (insanity without hallucinations or delusions). See Prichard, James Cowles (1835).

   Distinction between momentary symptom picture and underlying disease process in psychiatry (1844). To some extent, physicians have always been aware that the symptoms at any moment are conceptually different from the underlying disease producing them (mumps in one moment can produce a swelling, in another, a fever). Yet, psychiatry has long had a tendency to make symptomatic diagnoses (e.g., kleptomania as a separate disease). In 1844, Carl Friedrich Flemming (1799–1880), chief physician of the newly opened asylum Sachsenberg, near Schwerin, made the explicit distinction: "With mental disorders we are not dealing directly with diseases but initially only with symptoms of diseases or with forms of unwellness." He told readers it was important to discern the actual diseases (Krankheiten) (General Journal of Psychiatry [Allgemeine Zeitschrift für Psychiatrie], 1844, p. 122).

   "Psychosis" introduced (1845). After Vienna’s Ernst von Feuchtersleben (1806-1849) had become secretary of the Medical Society, in 1844 he initiated a series of lectures on psychiatry. With William Cullen’s class of "neuroses" in mind—meaning disease of the central nervous system—Feuchtersleben in his lectures coined the term "psychosis": "Where psychic phenomena present themselves abnormally, we speak of mental illness [Seelenkrankheit]; it is rooted in the mind [die Seele], and insofar as these phenomena are transmitted through the brain [das sinnliche Organ], they are rooted in the body, because the brain is the organ of the mind." "Every psychosis [disorder of the psyche] is at the same time a neurosis [disorder of the brain], because without the mediation of the nervous system no mental change is able to become manifest; but every neurosis is not simultaneously a psychosis" (p. 265). Psychosis and neurosis soon acquired directly opposite meanings from those intended by Feuchtersleben, who associated psychosis with mind, and neurosis with brain. His lectures were published in 1845 as The Principles of Medical Psychology (Lehrbuch der ärztlichen Seelenheilkunde). (Cullen had introduced "neurosis" in 1777.) The concept of "psychosis" was then disseminated within medicine by Carl Friedrich Flemming’s influential 1859 textbook, Pathology and Treatment of the Psychoses (Pathologie und Therapie der Psychosen).

   Mania and melancholia as a result of degeneration (1857). In his Treatise on Degeneration (Traité des dégénéréscences physiques, intellectuelles et morales de l’éspece humaine), French psychiatrist Bénédict-Augustin Morel (1809–1873), medical supervisor of the St.-Yon asylum near Rouen, ascribed major psychiatric illnesses to the process of degeneration, an inherited tendency to disease as a result of poisoned ancestry. "Mental illness is degeneration," he wrote (p. 682). Across the generations, the signs of degeneration would, he said, become steadily more evident, resulting ultimately in sterility. There was evidence of a lesion of some kind in degeneration because asylum patients often have a "special cachet in their physiognomy" (p. 346). This was not the first doctrine of genetics in psychiatry, but it reverberated powerfully over the years and into the Nazi period. (See also Hypomania and Mania; Psychiatric Genetics.) Dementia praecox (démence précoce) (1860). See Schizophrenia: Emergence. Kahlbaum’s Vesania typica (typical insanity) (1863). See Schizophrenia: Emergence.

   Delusions and hallucinations as a separate illness (not a late stage of melancholy) (1865, 1867). Two German psychiatrists share the priority in seeing delusions and hallucinations as a separate illness ("primary"), not as a stage of mania or melancholia. Snell: In 1865, Ludwig Daniel Christian Snell (1817–1892), superintendent of the asylum in Hildesheim, Germany, and pioneer of asylum farm-colonies, proposed that delusions and hallucinations (Wahnsinn) represented a "primary form of mental disturbance," distinct from melancholia (because of patients’ elevated self-esteem) and from mania (because of the absence of flight of ideas and similar manic symptoms). He thought "monomania" an appropriate term. In his experience, mania and melancholia went downhill into various psychic endstages, but did not turn into monomania. Hence, monomania must be "primary" (Allgemeine Zeitschrift für Psychiatrie, 1865, quotes pp. 368–369).

   Griesinger: Two years later, in his lecture in May 1867 on the occasion of the opening of the new psychiatric clinic at the Charité Hospital in Berlin, Wilhelm Griesinger said that delusions and hallucinations were "primary" forms of insanity (Primordialdelirien) that arose de novo without pathological emotions such as melancholy as precursors. Common forms were persecutory ideas involving suffering or expansive expressions of grandiosity. Griesinger cited Snell (as well as Morel’s 1860 book that mentioned démence précoce) but went one step beyond them: inspired by the model of neurosyphilis, he hypothesized underlying brain disease as the cause of the delusions: "the ganglion cells of the cerebral gray matter." In the first edition of his textbook in 1845, Griesinger had denied the primordial nature of delusions and had considered mania and melancholia to be "primary disorders" (Elementarstörungen) (p. 49). Now he had turned a page. The lecture was published in 1868 in volume 1 of Griesinger’s new journal, The Archive of Psychiatry and Nervous Diseases (Archiv für Psychiatrie und Nervenkrankheiten).

   Hebephrenia (1871). See Schizophrenia: Emergence.

   Catatonia (1874). See Schizophrenia: Emergence. See Paranoia, 1883.

   Chronic systematized delusional disorder (délire chronique à évolution systématique) (1886, 1888, 1892). Beginning in 1886, Paris psychiatrist Valentin Magnan, in charge of the intake service at the Ste.-Anne mental hospital, introduced colleagues at the Medical-Psychological Society to his conception of a chronic kind of wellcircumscribed delusional disorder that went through four stages after a period of incubation: inquietude-hallucinations, persecution, manic-grandeur, and dementia. The delusions were highly structured, hence the adjective "systematic," or "systematized." In 1888, Magnan published a series of articles on it in Le Progrès médical, then in 1892 together with his colleague Paul Sérieux (1864–1947), he described the disorder in a monograph entitled Le délire chronique à évolution systématique. Magnan attributed great importance to degeneration in other psychiatric illnesses and built considerably on the work of his teacher Prosper Lucas (1808–1885), who in 1850 had highlighted the importance of heredity in psychiatry (Lucas, Philosophical Treatise on Natural Heredity [Traité philosophique de l’hérédité naturelle]), as well as on Ernest Lasègue’s "delusions of persecution" in 1852. (See Paranoia.) Yet, Magnan’s chronic systematized delusional disorder was found more in the "predisposed normal" than in the degenerate. In retrospect, it is difficult not to see Magnan’s creation as an early description of dementia praecox, although Magnan, like many French psychiatrists, detested Kraepelin’s term. (See also French Chronic Delusional States.)

   La Bouffée délirante, or transitory delusional psychosis (1886, 1891). In 1886, Valentin Magnan’s students Honoré Saury (1854–?) and Paul-Maurice Legrain (1860-1939), in books of their own, each described the master’s notions of la bouffée délirante, a concept so intensely French that even today in the international literature the French term is used. Then, in an 1891 monograph on chronic systematized delusional disorder (see above), Magnan himself mentioned these transitory (reactive) psychotic states, "bouffées délirantes," in contrast to the chronic downhill variety. Affecting mainly the degenerate, they might arrive out of the blue and then fade again as suddenly. Bouffées délirantes were widely diagnosed in French psychiatry and remain a nosological staple even today. After about 1910, the diagnosis lost the degenerative note.

   Meynert’s "amentia" (1890). Theodor Meynert described in his 1890 clinical lectures a form of sudden-onset confusion (Verwirrtheit), often with such psychotic symptoms as hallucinations, that he called "amentia," a term long in use in psychiatry for major illness (although following William Cullen’s "amentia congenita" [1777], many authors used amentia to mean mental retardation.) Meynert distinguished this from dementia. (Amentia was a thinking disorder, whereas "dementia" was a personality deterioration.) Symptoms of amentia ran the gamut from excitement to stupor. Meynert saw amentia as relapsing but only occasionally ending in deterioration. He attributed it to disorders in the association fibers between the frontal lobe and other centers. "In almost every episode of confusion, remissions alternate with intensive symptoms, in the form of recovery and exhaustion. Sometimes the patients are confused in the morning . . . clearer towards evening. . . . Even in episodes of confusion they respond with rational declarations to external events. . . . In milder cases, the physician must not expect to find the patients continuously confused, but always prone, indeed prepared, to relapse into deep exhaustion and confusion" (p. 107). Meynert’s diagnosis met a rather ignominious end as Emil Kraepelin took it up, then in the eighth edition of his textbook (1910) assimilated "acute confusion (amentia)" to the forms of febrile delirium. Yet, the memory of "amentia" lingered on in Vienna among such Meynert students as Josef Berze (1866–1958) as yet another Viennese equivalent of Kraepelin’s all-conquering "dementia praecox." (See SCHIZOPHRENIA: EMERGENCE: Stransky’s intrapsychic ataxia [1903].) In 1936, Berze wrote in his memoir, "Meynert and Schizophrenia," in the Journal of Combined Neurology and Psychiatry (Zeitschrift für die gesamte Neurologie und Psychiatrie), "Meynert . . . with his amentia had essentially the same kind of cases as Kraepelin and Bleuler." Between Meynert’s "deficit in association" and Bleuler’s "loosening of association" there was not such a big difference, Berze said (p. 273). Berze believed that if Meynert had lived, he rather than Kraepelin would have had the priority.

   Emil Kraepelin’s dementia praecox (after 1893). See Schizophrenia: Emergence.

   Bleuler’s schizophrenia (1908, 1911). See Schizophrenia: Emergence. See French Chronic Delusional States (from 1909).

   Karl Jaspers’s "pathological jealousy" (meaning a delusion with jealousy as its content; Eifersuchtswahn) (1910). (See Paranoia.) Jaspers did not believe in Kraepelin’s dementia praecox as a single large disease. But, he did recognize that some psychoses probably had an underlying organic basis. In order to distinguish between psychotic patients whose prognosis was good from those whose was not, Jaspers differentiated between patients whose delusional jealousy was simply an extension of their lifelong suspiciousness ("personality development" patients [Entwicklung einer Persönlichkeit]) and "process" patients, whose symptoms came out of the blue on top of a basically normal premorbid personality. The "developmental" patients had good prospects for recovery; the "process" patients, whose normal mental life had been interrupted by a somatic disease, did not. Jaspers was not the first to use the term "process" as implying an organic illness with inexorable change. (The concept goes back to Heinrich Neumann’s Textbook of Psychiatry in 1859.) Yet, the distinction between development and process became fundamental for several generations of psychiatrists, and as late as 1998 Paul McHugh (1931–), chair of psychiatry at Johns Hopkins University, and his colleague Phillip Slavney (1940–) mused about it in their book, Perspectives of Psychiatry (second edition). Jaspers’ 1910 paper appeared in the premier volume of the Journal of Combined Neurology and Psychiatry (Zeitschrift für die gesamte Neurologie und Psychiatrie). See Freudian Interpretations of Psychosis and Schizophrenia (1907).

   Psychogenic (reactive) psychoses (1916). August Wimmer (1872–1937), then director of St. Hans Psychiatric Hospital near Roskilde, Denmark, and chair of psychiatry at the University of Copenhagen from 1921 to 1937, published in 1916 the first comprehensive account of the reactive psychoses, Psykogene Sindssygdomsformer (Psychogenic Forms of Mental Diseases). "[Their] distinctive feature is that they most often occur on a predisposed terrain that is exposed to psychological traumata," in the words of biographer Johan Schioldann-Nielsen (History of Psychiatry, 1993, p. 414). Wimmer did not actually discover the concept of reactive psychoses, which had been widely discussed in psychiatry at the turn of the century. He had been influenced by Magnan’s 1893 concept of bouffées délirantes and by his 1895 book, Les Dégénérés (although Wimmer’s key concept was reaction, whereas Magnan’s was degeneration). Unlike the chronic conditions described by the French and Germans, these psychotic episodes remitted quickly. Wimmer’s work was never translated into English but became a building block of Scandinavian psychiatry.*

   In 1968, Erik Strömgren revived Wimmer’s concept in an influential paper on "reactive psychoses," a term that he changed in 1974 to "psychogenic psychoses." (This appeared in a volume of classic papers in European psychiatry edited by Steven R. Hirsch [1937–] and Michael Shepherd.) "It must be stressed that these psychoses are regarded as being psychogenic in a restricted sense," he wrote. "The mental trauma must be of such a nature that the psychosis would not have arisen in its absence." He divided them into three groups: emotional reactions, disorders of consciousness, and paranoid states" (pp. 100–101). Strömgren later expressed bafflement that the concept of psychogenic psychosis, which represented around 10% of all admissions to Danish psychiatric hospitals, was viewed by the World Health Organization in its International Classification of Diseases as "rare" (Shepherd, Psychiatrists, p. 166).

   Sensitive delusions of reference (sensitiver Beziehungswahn) (1918). This was the first important concept of Tübingen psychiatrist Ernst Kretschmer. His chief, Robert Gaupp, was intent upon demonstrating the existence of delusional disorders in patients who did not have schizophrenia (but rather reactive paranoia) and doubtless steered Kretschmer in this direction. Kretschmer postulated delusions as an independent illness in patients who did not have the underlying brain disease schizophrenia but rather were vulnerable because of specially "sensitive" premorbid personalities. The distinction that Karl Jaspers had made in 1910 between developmental illnesses in individuals with healthy personalities (in whom the illness was "understandable") and "process" illnesses in individuals with underlying brain disease (in whom the illness was not "understandable") was quite influential in German psychiatry in those years, and Kretschmer identified here a series of transitions involving delusions and hallucinations between developmental forms and process forms. Kretschmer’s book Sensitive Delusions of Reference: A Contribution to the Question of Paranoia and to the Doctrine of Character in Psychiatry (Der sensitive Beziehungswahn: ein Beitrag zur Panaroiafrage und zur psychiatrischen Charakterlehre) was published in 1918 and translated into several languages, being reissued as late as 1966. The diagnosis did not really catch on until after the Second World War. Some observers believe, however, that many patients with this diagnosis in fact have schizophrenia (Gruhle in Wilmanns, Schizophrenie, p. 30).

   * Johan Schioldann-Nielsen, an Adelaide psychiatrist of Danish origin, currently has an English translation forthcoming from Adelaide Academic Press, with forewords by German Berrios and Nils Retterstol.

   Kretschmer’s constitutional psychoses (1921). Trying to make a link between physical type, personality, and illness, Kretschmer postulated in his book Body Type and Character (Körperbau und Charakter) the existence of three basic body types: athletic, meaning robustly developed skeleton, muscles, and skin, slightly prone to schizophrenia; asthenic, meaning thin bodies and limbs, prone to schizophrenia; and pyknic, large body-cavities (abdomen, thorax, cranium), tendency to fat, plus rather delicate limbs, prone to manic-depressive illness. "The manner in which these three types are distributed within schizophrenic and manic-depressive illness (circular) is very diverse and quite remarkable. Among healthy people as well, we find these types recurring everywhere, so they do not entail anything pathological in themselves. . . ." (seventh ed., 1929, p. 17). These associations between body type and psychiatric illness had a large impact on research in the next decades. In 1932, Kurt Schneider judged Kretschmer’s body-type classification "the only really big contribution to clinical psychiatry since Kraepelin" (Schneider, Problems of Clinical Psychiatry [Probleme der klinischen Psychiatrie], 1932, p. 12).

   Periodic catatonia (1932 and after). In 1932, Rolf Gjessing (1889–1959) of the Dikemark Psychiatric Hospital in Oslo, Norway, began the first of his lifelong investigations of the periodic forms of psychosis that Kraepelin (see Schizophrenia: Emergence) in 1913 had assigned to dementia praecox. By the time of Gjessing’s 1938 article in the Journal of Mental Science, he linked the attacks to sharp periodic shifts in the body’s nitrogen balance. The abnormal levels of nitrogen were treatable with the thyroid hormone thyroxin. This represents the first successful attempt to connect a schizophrenic syndrome with a biochemical body change. (Such conditions are rarely seen today because antipsychotic drugs have obliterated their periodicity.)

   For further developments, see Schizophrenia: Recent Concepts.