Abstract
Scandinavia's contribution to psychiatric nosology is little acknowledged. Langfeldt's schizophreniform psychosis survives in DSM-IV as ‘schizophreniform disorder – with good prognostic features’ but with criteria unrelated to the original concept, although clouding of consciousness as a feature is preserved. The concept of ‘psychogenic psychosis’ survived in DSM-III and DSM-III-R as ‘brief reactive psychosis’ but it is killed off in DSM-IV, incorporated into ‘brief psychotic disorder’ although a specifier ‘with marked stressors’ remains. The ICD-10 has a superordinate category ‘acute and transient psychotic disorders’ containing subcategories predominately used in continental Europe, such as cycloid psychosis and boufee′ delirante and a schizophreniform disorder akin to Langfeldt's sans name. ‘Psychogenic paranoid psychosis’ and ‘reactive psychosis’, appear as an afterthought without criteria.
Does this mean that psychogenesis in psychotic disorders is dead or dying? In the foreward German Berrios rephrasing Camus suggests that ‘there is only one truly serious question in psychiatry and that is psychogenesis’. Are there then no longer truly serious questions in psychiatry?
Psychogenesis may have a new lease of life in traumatology, but even in a quintessentially psychogenic disorder like PTSD where the trauma is the necessary and sufficient condition for the development of the syndrome, it is increasingly seen as an organic condition of the brain wrought by trauma. Thus particular varieties of psychogenesis are seen as producing specific ‘footprints’ in the brain (Berrios).
In a scholarly account of the conceptual history behind Wimmer's psychogenic psychosis, Schioldann draws together various European streams but the concept reaches arguably its finest conceptualization in Jaspers' (1913) distinction between ‘pure precipitation psychosis’ and ‘genuine reactive psychosis’. Wimmer's criteria for psychogenic psychoses are almost identical to Jaspers' reactive psychosis. So who influenced whom? Schioldann argues that rather than one or other having primacy it is likely that both drew together what was current thinking around the time. Notably however, the underlying philosophical basis is clearly Jasperian as it hinges on the concept of ‘understandability’.
The Jaspers-Wimmer criteria are worth remembering as a standard against the wild psychogenesis that passes for aetiological formulation, particularly in the medicolegal field. Basically they boil down to this: for a condition to be considered ‘reactive’ or ‘psychogenic’ there must be a clear temporal relationship between the psychic trauma and the emergence of the condition, the form and content of the condition must be understandable in terms of the trauma and, moreover, when the individual is removed from the adverse situation, or the trauma ceases, there is remission of symptoms. Contrast this with what Meehl has called the ‘spun glass theory of mind’ wherein psychic trauma, even sometimes minor trauma, causes long-term and irreparable disability.
Dr Schioldann has done English-speaking psychiatry a great service by translating Wimmer's important monograph. Our previous knowledge of Wimmer was restricted to Stromgren's reprinted paper on ‘Psychogenic psychoses’ in Themes and variations in European psychiatry edited by Hirsch and Shepherd (1974). Interestingly Stromgren then made the comment: ‘It may well have been that most of the controversies within our field could have been avoided had this monumental work been translated into English after its publication’.
Wimmer's book is made all the more enthralling by the rich case vignettes. Why aren't we seeing these sorts of patients today? The answer probably lies in the fact that we are looking at patients with different conceptual filters. How would we classify them today? A significant proportion appear to be depressive psychoses or paranoid states but others have a more clearly schizophreniform picture. Curiously some of the cases seem clearly to represent obsessive compulsive disorder. Others suggest psychotic states in borderline personalities. More curiously some of the cases do not have psychotic symptoms as such which begs the question as to whether Wimmer is using the term ‘psychosis’ in the modern sense or in the sense of severity of illness. What is even more intriguing is that in quite a few of the vignettes it is not at all clear whether the Jaspers-Wimmer criteria actually apply.
If learning psychiatry has become boring (ask a random group of psychiatric trainees) it is arguably because we are no longer challenged by serious questions. However, this does not necessarily mean serious questions no longer exist. Hopefully questions such as what ‘psychogenesis’ and ‘reaction’ mean and indeed what they don't mean remain relevant and the works of Jasper and Wimmer are not merely of historical interest.