Historical development of the diagnostic concept

An unexplored area of research in neuropsychopharmacology 

Thomas A. Ban, M.D.

PREHISTORY: THE TERM AND ITS MEANINGS

The origin of the term, "paranoia",  was in the Greek  word "par-a-noy'a", derived from the verb "para-noeo", with the literal meaning of "derangement", or "departure from the normal" ("para") in "thinking" ("noeo") (Stedman's 1990).  It was used in Ancient Greece either loosely as we use the words "folly" and  "crazy" (Lewis 1970), or in a sense as we use "insanity" (Encyclopedia Britannica 1969) and "madness" (Webster's 1985), terms, introduced by Aurelius Cornelius Celsus, during the reign of Tiberius (14 - 37) and William Battie in 1758, respectively.

Tracing the usage of the term, (in his review of the history of the concept), Aubrey Lewis (1970) noted, that the term, "paranoia", first appeared in the plays of the great Greek tragedians, Aeschylus (525-456 BC), Euripides (485-407 BC) and Aristophanes (450-388 BC).   During the same period it was also used by the philosophers, Plato (428-348 BC) and Aristotle (343-322 BC), as well as by the physician, Hippocrates (450-355 BC).

After dormant for about two millennia, the term, "paranoia" was revived during the second part of the 18th century in the writings of the "nosologists". It  reappeared first, in Francois Boissier de Sauvages' (1759) Pathologia Methodica, in France, and subsequently, in Rudolph August Vogel's (1772) Academicae Praelectiones, in Germany, and William Cullen's (1776) First Lines of the Practice of Physik, in Scotland. Nevertheless, while for Hippocrates (450-355 BC), "paranoia" was equivalent with the "delirium" of "high fever", the prevalent characteristic of "phrenitis", and for Boissier de Sauvages (1763), with "amentia", using the term  "amentia" and "dementia" interchangeably, for both, Vogel (1772) and Cullen (1776), it was equivalent with "vesania", or "morbus mentis", which included "mania", "melancholia", "fatuitas", "stupiditas", "amentia", and "oblivion".

With the adoption and inclusion of the term by Johann Christian Heinroth (1818) in his influential Lehrbuch der Storungen des Seelenlebens --the same text in which the term, "psychiatry", he adopted from Reil (1803), first appeared-- the prehistory of "paranoia" ends, and the development of the nosologic-diagnostic  concept of "paranoia" begins.

DEVELOPMENT OF THE DIAGNOSTIC CONCEPT

HEINROTH'S VERRUCKTHEIT

Heinroth (1818) used the Greek term, "paranoia", and the German term, "Verrucktheit" interchangeably.  He conceptualized "paranoia" as a "disorder of intellect" with preserved "feelings" ("emotions") and "will" ("volition").  However, while he was studying patients, who assumedly fulfilled these primary characteristics, and, described four distinct "species'" of the disease, he recognized, that ideal ("pure") cases were rare, and in the vast majority of patients the symptoms were not restricted to "intellect", but involved also other "mental faculties" (Fish 1962;  Hamilton 1976).  Most of the "pure cases", he found were among the patients with "ecnoia", the "species" of the disease, in which "a single false idea was responsible for gross distortion of a subject's relation with the outside world.

But, even if "Verrucktheit" did not provide a sufficiently homogenous population, Heinroth's (1818) introduction of the term, "paranoia", and his conceptualization of it as a "partial insanity" ("delire partial"), a popular concept at the time among the "French alienists", represents the first step in the history towards the development of the "nosologic entity" of "paranoia", to be introduced in the 1860s.

ESQUIROL'S INTELLECTUAL MONOMANIA

For well over four decades after the publication of Heinroth's (1818) text, the term "paranoia" was virtually absent from the "psychiatric literature" , even within the "German culture of psychiatry"; and as of to date, it has never been an accepted term for medical use in France.  In spite of this, the second important step in the conceptual development of "paranoia" resulted from Esquirol's (1838) adoption of "partial insanity," in his classification of "mental illness", which was to become the basis for the classification of mental illness in the French speaking world for well over 50 years.

After recognizing "partial insanity", i.e.,  "insanity" with symptomatology restricted to one major "mental faculty", as a distinct category of disease, and,  separating "partial insanity", referred to as "monomania", from "total insanity", referred to as "mania" in his classification, Esquirol (1838) identified  "intellectual monomania", the corresponding diagnostic concept to Heinroth's (1818) "paranoia".  Furthermore, by describing the formation of "delusional systems", via "logical reasoning", from a "single false idea", the second essential characteristic of the disease, he filled in the gap, left open by Heinroth (1818), between the "single false idea", and the "gross distortion of the subject's relation with the outside world".  Finally, by recognizing that patients with "intellectual monomania", aside from the areas, relevant to their "delusional systems", "think, reason, and act, like other men", Esquirol (1818) identified the third essential characteristic of the disease which was to become known as "paranoia".                

GRIESINGER'S CHRONIC MANIA

Esquirol's (1838) nosologic concepts in France were included in Germany, (as shown in Table 7), in Griesinger's (1845) classification of "mental syndromes" ;  and the third important step, in the development of "paranoia", resulted from Griesinger's (1845) mixing of the "dimensional" diagnostic concepts of "unitary psychosis", with the "categorical" diagnostic concepts of Esquirol's (1838) General Forms of Insanity.

The diagnostic concepts of "unitary psychosis" are based on the adoption of Bayle's(1825) findings in "general paralysis", as the "model" for "mental illness" .  They are derived from the different "mental syndromes", which represent the different developmental stages of the "disease process", that progresses from a "reversible confusional state" ("delire monomaniaque"), Griesinger (1845) referred to as "monomania", through a "state characterized by dominant ideas" ("delire maniaque"), he identified as "Die (the) Verrucktheit", or "La Folie Systematisee", and referred to as "chronic mania", to a "state characterized by personality deterioration" ("etat de demence"), he referred to as "dementia".  It was with consideration of this frame of reference, that Griesinger (1845) separated  the "reversible partial insanity of monomania", with selective symptomatology for one mental faculty, i.e., "intellect", from the "irreversible partial insanity of chronic mania", which, in turn, he separated by the lack of "personality deterioration", from the irreversible states of "mental weakness", e.g., "dementia"

By recognizing the lack of "personality deterioration" in patients with "chronic mania", Griesinger (1845) identified the fourth essential characteristic of the disease, and set the stage  for Kahlbaum (1863), to introduce "paranoia" .

HISTORY: THE CONCEPT AND ITS DIFFERENTIATION

INTRODUCTION BY KAHLBAUM

The "nosologic entity" of "paranoia" was introduced by Karl Kahlbaum in his "dissertation" for "habilation", to qualify for "private docent", at the University of Konigsberg in 1863.  The title of the "dissertation" was, Gruppierung (Classification) der psychischen Krankheiten  (of Psychic Illness'), with the "ambitious" (Pichot 1983) subtitle, Versuch zur Anbahnung einer empirisch-naturalwissenschaftlichen Grundlage der Psychiatrie als Klinische Disziplin, which translates into English as An Attempt for Developing  an Empirical-Naturalscience Based Foundation for the Clinical Discipline of Psychiatry.

On the basis of information on the entire course of psychiatric disease, and with consideration of the prevalent conceptual frameworks of psychiatry in his time, Kahlbaum (1863), divided mental illness into five categories of disease, i.e., "vesanias", "vecordias", "dysphrenias", "neophrenias" and "paraphrenias". And on the basis of his clinical experience, with consideration of the contributions of Heinroth (1818), Esquirol (1838), and Griesinger (1845), through their characterization of "ecnoia", "intellectual monomania", and "chronic mania", respectively, he identified "paranoia", as one of the three forms of the "vecordias", i.e., "partial insanities", in which  the symptoms (or syndromic expression) of the disease remain essentially unchanged and restricted (limited) to one mental faculty ("intellect") during lifetime.  As a "vecordia", paranoia is distinct from the insanities of the "vesanias", i.e., "total (or general) insanities" in which the syndromic expression of the insanity changes through different developmental stages until it reaches "dementia"; from the "dysphrenias", i.e., symptomatic diseases linked to somatic illness ;  from the "neophrenias", i.e., disorders which are inborn, or have an onset shortly after birth; and from the "paraphrenias", i.e., illnesses with an onset at periods of transition in biologic development, such as "puberty", and "involution".

Paranoia, with Kahlbaum's (1863) conceptualization, became a distinct "nosologic entity", a "primary disease", with the necessary "qualifications" ("descriptive features") for clinical use. Although for some time it was still interchangeably used with Heinroth's (1818) term, "Verrucktheit"(Sander 1868), and with Esquirol's (1838) term, "monomania"(Snell 1865), by the end of the 1860s, the concept was accepted ; and, the debate whether "paranoia" is a "primary" (Snell 1865; Seglas 1888) or "secondary" (Griesinger 1845; Mendel 1884), an "acute" (Westphal 1878) or "chronic"  (Neisser 1891; Specht 1901) disease, a disease of "intellect" (Heinroth 1818; Kahlbaum 1863) or "judgement" (Sander 1868), "understanding (Westphal 1878) or "affect (Specht 1901), began with Sanders (1868) assertion, that "Primare Verrucktheit", as he still called "paranoia", is a "hereditary disease, in which intelligence remains intact, but there are delusions of persecution and self-aggrandisement, indicating abnormal judgement about the relation between the self and the outer world".

MOLDING OF THE CONCEPT

In subsequent years there was a considerable molding of the concept, with attempts to expand (widen), or restrict (narrow), its scope, or even to incorporate it into another, broader diagnostic concept.

WIDENING THE SCOPE

Attempts to widen the scope of "paranoia", began, as early as 1878 with Westphal's description of "acute paranoia". Considerations that "paranoia" may also be displayed in the form of an "acute-reversible" illness, lead to the inclusion of "transitory delusional psychosis" ("bouffee delirante") (Legrain 1886; Saury 1886), the corresponding diagnostic concept with Westphal's (1878) "acute paranoia", in the French classification of "psychiatric disorders" (Seglas 1888).

Later on, with the introduction of the diagnostic concept of "psychogenic psychosis" by Wimmer in 1916, and the recognition that of the different "types" of "reactions", the "paranoid" is third in terms of frequency of occurrence (Schneider 1927), the possibility was entertained that "paranoia" may also have a "reactive" form.In favor for extending the scope of "paranoia" to include "psychogenic paranoid psychosis" were findings that the symptomatology of "psychogenic paranoid psychosis", and the symptomatology of Kretschmer's (1927) "sensitive delusions of reference", is virtually indistinguishable (Stromgren 1958).                      

NARROWING THE SCOPE

At the other end, attempts to restrict the scope of "paranoia" , began as early as 1891 by Werner's separation of the "simple" ("pure") form of "paranoia", from the "hallucinatory" form. The notion that in terms of "prognostic predictions", and especially of "course" and "outcome" , the "non-hallucinatory" form provides a more homogenous population, lead to the restriction of the concept of "paranoia" to the "non-hallucinatory" form , and to the separation of "chronic interpretative psychosis" (Serieux and Capgras 1909), from "chronic hallucinatory psychosis" (Ballet 1911, 1913), within the "chronic delusional psychoses" in France;  and to the separation of "simple delusional disorder" (Winokur 1977) from "hallucinatory delusional disorder" (Kendler 1980) in the United States. 

A further restriction in the scope of "paranoia" was triggered by the publication of Jaspers (1910) seminal paper on "morbid (delusional) jealousy".  It yielded considerations to exclude from "paranoia" the subpopulation with a "psychologically understandable" ("meaningful"), "paranoiac development".  The concept of "paranoiac development", a "developmental anomaly", in variance with "paranoia", a disease, received strong impetus in Europe by Gaupp's (1914 a & b ; 1938)) publication of the case of Ernest Wagner, a schoolmaster, who became a mass murderer;  and from Kretschmer's (1927) influential monograph, on the "sensitive delusions of reference", in which, he postulated that in "sensitive personalities" {about their own shortcomings), a full-blown "paranoid psychosis" may develop in "reaction" to a "key experience" (that exposes their weakness).  Paranoiac development had also a powerful proponent in the United States in Adolf Meyer (1917,1952), who perceived it as the fourth of his six "pathergesias", i.e., "pathologic reactions", the third being "delirious reaction", and the fifth, "affective reaction" (Billings 1939).     

ENGULFING THE CONCEPT

The methodology, Jaspers (1910, 1913) offered for the separation of "developmental anomalies" from "disease" without the corresponding protective conceptual framework of distinguishing, between "development" and "process", "understanding" ("meaningful connections") and "explaining" ("causal connections"), and the "content" (the language of development) and the "form" (the language of disease) of "psychopathologic symptoms, opened a Pandora box in "psychiatry".  The "psychologically understandable", appeared to be flexible to the extent, that it lead to concerns, that "paranoia" will be engulfed by "paranoiac development". This, however, was not to become the case. By the time the concept of "paranoiac development" emerged, "paranoia" had already proven its durability. It had already survived the danger of becoming engulfed,  in Magnan's (1893) all embracing diagnostic concept of "chronic delusional psychosis of systematic evolution", as it was to survive later on Kolle's (1931) challenge to become engulfed in Bleuler's (1911) "schizophrenias".  In fact, nothing , prior to the virtually overlapping diagnostic concepts of "delusional (paranoid) disorder" of the DSM-III-R of the American Psychiatric Association (1987), and "delusional disorder" in the ICD-10 of the World Health organization (1992), had any tangible effect on the historically validated, (by overlaping descriptions at different points in time from different parts of the world), concept.  While still there,(as shown in Table 14), just as fully differentiated (into "paranoid state simple", "paranoia", "paraphrenia", "induced psychosis", "other paranoid states", and "unspecified paranoid states") as ever, at the time of its 104th birthday, in the ICD-9, by the time of the publication of the ICD-10 , just 15 years later, "paranoia",had been engulfed in the artificially created "consensus based diagnostic construct" of "delusional disorder", and, reverted into the amorphous state, it had been about 100 years ago, prior to Kraepelin's (1921) consolidation by careful differentiation from other empirically and/or conceptually derived  diagnostic concepts.

DIFFERENTIATION :FROM KRAEPELIN TO THE ICD-9

Kraepelin (1899) recognized "paranoia" as a "nosologic entity" in the 6th edition of his textbook, at a time when the term, "paranoia" was already widely used in Germany and the United States  (Tuke 1892), but the diagnostic concept was still in an  amorphous state. He introduced "paranoia" in the same edition of his text in which he introduced "dementia praecox", and during the years which followed, transformed "paranoia" from its "amorphous state", into the most homogenous diagnostic group among the "psychoses" with an "insidious onset" and "chronic continuous course". Furthermore, by differentiating "paranoia", from all the different diseases  with which it shares anything in common  --including "dementia paranoides" (characterized by "personality deterioration"), "paraphrenia" (characterized by "perceptual pathology" in the form of "hallucinations"), "emotional delusional states" (e.g., "querulant delusional psychosis", on the basis of "emotional loading"), "paranoiac development" (on the basis of the "connection with a definite external occasion"), and "paranoid psychosis", a "residual category" of patients which did not fit any of the other diagnoses--  Kraepelin (1921) succeeded in isolating a psychiatric disease, which, because of the selective nature of its psychopathology, is particularly suited for "biological" and especially for "psychopharmacological" research.

POSTHISTORY FUTURE PERSPECTIVE

In spite of the recognition that the "psychopathology" induced by amphetamines, is closest to the "psychopathology of "paranoia", "paraphrenia", "transitory delusional psychosis", or "paranoid states", the fact remains that amphetamine reversal, as a pharmacological screening test, was not used in the screening for drugs in the treatment of "delusional psychoses", but in the screening for drugs in the treatment of schizophrenias. In fact, it is very little known about the effects of psychotropic drugs in "paranoia." Although there are some isolated reports indicating that pimozide, a selective dopamine D-2 receptor blocker is therapeutically effective in monosymptomatic hypochondriacal psychosis and "erotomania" erotomania, “paranoia” has remained to-date, one of the unexplored areas of neuropsychopharmacological research.

SELECTED REFERENCES                                                                       

Esquirol JD.Mental Maladies. Treatise on Insanity. Translated from the  French  with additions  by E.K.Hunt,M.D. Philadelphia: Lea  and  Blanchard;1845.

Griesinger W. Mental  Pathology and Therapeutics.  Translated  from the German Second Edition  by  C. Lockhart  Robertson, M.D. London: The New Sydenham Society; 1867.

Kahlbaum K. Catatonia. Baltimore: The Johns Hopkins University Press; 1973.

Lewis A. Paranoia and paranoid: A historical perspective. Psychological Medicine 1970;1:2-212.

Barry Blackwell and David Paul Goldberg: Sir Aubrey Lewis and psychopharmacology

Barry Blackwell’s reply to Edward Shorter’s comments

       It was encouraging and delightful to read Edward (“Ned”) Shorter’s endorsement of the need for critical thinking and the manner in which its absence in contemporary practice and educational programs has become the norm. Below is what I hope is a timely example, offered as counterpoint.

Treating the Mind

       I hope NIMH members will have read my review of Daniel Carlat’s book Unhinged  and my commentary that was posted to inhn.org on June 27, 2019. It documents the pronounced change in clinical practice and training in psychiatry between the mid-1970s and the mid-1990s. In just two decades America went from ubiquitous psychoanalytic formulations and treatment in which medication was disparaged and discouraged to the contemporary practice confined primarily to med-checks minus therapy which, if indicated, is farmed out to other mental health providers.

        An historical re-capitulation of four factors leading to the contemporary “medicalization”  of society may be timely.

1.      A draught of innovative discoveries and lack of novel insights into brain mechanisms from the late 1970s  to the present has led the pharmaceutical industry to abandon its search and instead focus its resources on strenuous and seductive advertising of “me-too” products generating vast profits that fund extensive lobbying of Congress, extend patents and incentivize the FDA to approve its efforts by inflating its budget (Blackwell 2016).

2.      The industry goals are aided by a diagnostic system (DSM) based on symptoms derived from clinical consensus rather than classical nosology or epidemiology. The symptoms of depressive- and anxiety-based disorders have become codified as “medical disorders” sometimes matching a specific drug to a particular “disorder.”

3.      Persuaded by ingenious advertising and backed by complicit well-payed medical opinion leaders (e.g., “key opinion leaders” [KOL]) anxiety and depression have become parsed as exclusively medical disorders requiring drugs as the inevitable first choice treatment, enhanced by the training and practice of psychiatry becoming reduced to “med checks” divorced from verbal therapy. The main prescribers of psychotropic drugs are primary care physicians, often misled by KOL “educational” sessions, who find it difficult to make diagnostic or therapy referrals due to the increasing shortage of mental health professionals and long waiting times, coupled with insurance coverage that favors medication management over talk therapy, despite evidence that dealing with mental health issues produces significant reductions in the cost of co-morbid medical care - the medical offset.

4.      The least discussed and most insidious aspect of this contemporary medicalization is an absence of any encouragement to view the onset of physical and emotional symptoms as a failure to acknowledge anxiety as an anticipatory response to everyday existential challenges, just as depression is a retrospective rumination on the failure to achieve a desired outcome. Of course, people differ in their responses. For some anxiety is a spur to further effort and depression a lesson  learned from  an unwise effort. Some folks have heightened awareness of physical sensations (symptom sensitivity, unkindly hypochondriasis) while others, deprived of affection in early life, lack an emotional vocabulary (alexithymia) and communicate in body language. 

       Whatever benefits contemporary psychotropic medications bestow, perhaps limited to a diminished placebo response, will evaporate on discontinuation, leaving no new behaviors to cope with re-emerging life predicaments. Relapse and return to the same or a new drug establishes dependency with a conviction that weaning or doing without medication is impossible. This is a recipe for despair, perhaps even suicidal ideation. Increasing rates of drug dependency, failure of weaning and increasing suicide rates are features of the current situation..

       There is no better example of “throwing out the baby with the bath water” than the segregation of talk from medication management in affective disorders. (Blackwell 2017)

       The psychiatric profession is suffering along with its patients. The diagnostic quagmire that is now psychiatry is worsened by a severe shortage of psychiatrists and long waiting times to see one. A discipline that is mindless, unscientific and overworked is hardly the intriguing career it used to be in the first half of the 20^th century.

      Perhaps Ned Shorter, a distinguished historian, can comment on whether this commentary is valid criticism or the curmudgeonly musings of an 85-year-old  psychopharmacologist!

References:

Blackwell B. Corporate corruption in the psychopharmaceutical industry. inhn.org.controversies.  September 1, 2016.

Blackwell B. The baby and the bathwater. inhn.org.controversies. June 22, 2017.

Carlat JD. (Au) Unhinged  New York, Free Press . 2010.

October 24, 2019