Thomas A. Ban
Neuropsychopharmacology in Historical Perspective
Education in the Field in the Post-Neuropsychopharmacology Era
Wilhelm Griesinger and Unitary Psychosis (Einheitpsychose)
The concept of “unitary psychosis” (Einheitpsychose) is based on the notion that different clinical syndromes of “insanity” are varieties of a single universal madness with fluid boundaries (Jaspers 1963, 1997; Noll 2007).
The roots of the concept of “unitary psychosis” are in Antoine Laurent, Jesse Bayle’s (1799–1858) finding in the early 1820s that in chronic arachnitis (allegedly caused by cerebral syphilis), the dementia syndrome displayed in the final stage in the development of the disease, was preceded by other mental syndromes in the earlier stages of disease development. It was on the basis of these findings that in his Recherches sur les Maladies Mentales, published in 1822, Bayle put forward the notion that “the symptoms of chronic arachnitis can be reduced to a general and incomplete paralysis and to the derangement of intellectual faculties” (Bayle 1822). He also pointed out: “These two orders of phenomena (paralysis and intellectual derangement) proceed at an equal and proportional pace and allow the disease to divide into three periods:“delire monomaniaque,” with exaltation in the first;“delire maniaque,” with dominant ideas in the second; and “etat demence,”(dementia) in the third (Bayle 1825, 1826; Pichot 1983.)
A unitary concept of madness was first presented, in 1833, by Joseph Guislain (1797-1860, a Belgian physician, head of the psychiatric asylum in Ghent. In his Traité Des Phrénopathies ou Doctrine Nouvelle des Maladies Mentales, published in 1833, Guislain proposed that the origin (cause) of all of the almost 100 mental syndromes he recognized was in mental pain, which he referred to as phrenalgia (“phrenalgie”). It was on the basis of this etiological consideration that he perceived the various mental states (syndromes) displayed by patients as expressions of one and the same illness that unfolds along seven successive, progressive stages moving towards deterioration. The seven stages identified by Guislain were: hyperphrénie (mania); paraphrénie (paraphrenia); hyperplexie (stupidity); hyperspasmie (epilepsy); ideosynchysie (hallucinations); analcouthie (confusion); and noasthénie (dementia) (Angst 2002; Beer 1996; Guislain 1893).
Guislain’s concept of “unitary madness” was adopted by Ernst Albrecht von Zeller (1804-1877, the medical director of a private asylum in Winnenthal in Wurttenburg, Germany. He translated Guislain’s treatise to German from the French original and, in 1938, published it with a foreword (Beer 1996; Berrios and Beer 1994, 1995; Engstrom 2003; Guislain 1838).
Wilhelm Griesinger (1817-1868), adopted the diagnostic concept of “unitary psychosis” without its theoretical underpinnings while working as a medical assistant to Zeller in the early 1840s. Griesinger,a German physician who was to become director of the medical and psychiatric clinics of Charite Hospital in Berlin, perceived mental pathology as diseases of the “nerves” and believed,with consideration of Bayle’s (1822) findings,that “in the mental syndromes in which neuropathological changes are absent, they will become detectable at a later stage of disease development” (Ban and Ucha Udabe 1995).
In the first edition of his textbook, Pathologie und Therapie der psychischen Krankheiten, published in 1845, Griesinger (1845) postulated that mental activity is brain activity, based on "psychic reflex action” (psychische Reflexaktion) in which “stimuli of representations” (Vorstellungen), based on the individual’s life experience, play a similar role to environmental stimuli in the physiological reflex action (Berrios and Beer 1994; Engstrom 2003). He argued that both physiologic and psychic reflexes have the same mode of action and obey the same physical laws. He also contended that abnormal psychic reflex activity signals mental pathology; diminished activity leads to melancholia; and accelerated activity leads to mania.
After setting the conceptual foundation for a psychiatry that was to provide the functional underpinning on which neuropsychopharmacology was to be built upon in the second part of the 20th century, Griesinger (1861),in the first edition of his text in itssecond edition,elaborated his “unitary concept of psychosis.”It wasbased on recognition of three types of mental anomalies:one characterized by emotional disturbances; another by disturbances in intellectual and volitional functions; and a third by mental deterioration with a trajectory from “states of mental depression – melancholia,” through “states of mental exaltation” to “states of “mental weakness.” Further, on the basis of cross (trans) sectional clinical manifestations within the “states of mental depression – melancholia,” he distinguished hypochondriasis; melancholia; melancholia with stupor; melancholia with suicidal or murderous tendencies; and melancholia with persistent excitement of the will.Among the “states of mental excitement” weremania and monomania; and within the “states of mental weakness” were chronic mania, dementia, apathetic dementia, idiocy and cretinism (Menninger, Maymanand Pruyser 1969).
It was in 1859, between the publication of the first and second edition of Griesinger’s text, that Heinrich Neumann’s (1814-1888) Lehrbuch der Psychiatrie appeared. Neumann, the most vocal advocate of unitary psychosis, was owner of a private psychiatric clinic at the time his book was published.In 1874 he became the medical director of a university-based clinical ward in the Breslau city hospital (now Wroclaw in Poland). Neumann believed:“There is only one type of mental disorder. We call it madness (irresein). Insanity does not possess different forms but different stages; they are called insanity (wahnsinn), confusion (verwirrheit) and dementia (blödsinn).” He also extended the concept of einheitpsychosefrom a continuum between diseases to a continuum between diseases and health by arguing that "sleeplessness, illusions, exaggerated sensitivity... cause illness, then madness, confusion and dementia” (Beer 1996).
It was just about the same time that Neumann (1859) and Griesinger (1861) put forward their “unitary concept” that the first set of drugs was introduced – morphine and hyoscine for the control of excitement agitation and aggression (Wood 1855; Shorter1997); potassium bromide for relieving restlessness, anxiety and tension (Lockock 1857; Bettany 2004); and chloral hydrate and paraldehyde for calming and inducing sleep (Cervello 1883,1884; Liebreich 1869)– that profoundly affected the future course of psychiatry. Their effect provided the necessary changes for the collection of information and study of patients throughout their illness. With theinformation collected, by the 1920s psychopathology, the discipline that deals with the symptoms and signs of mental illness, and nosology, the discipline that deals with the rules of separating subpopulations and classifying these subpopulations, provided a foundation for psychiatrywith sub-populations which arguably have predictive validity. Yet, the concept of “unitary psychosis” lingered on.
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August 2, 2018