Psychopharmacology and the Classification of Functional Psychoses 

By Thomas A. Ban and Bertalan Pethö

Four-Dimensional Classification

Psychogenic Psychoses

Psychogenic (reactive) psychosis is a two-dimensional diagnosis. Accordingly, an essential prerequisite for this diagnosis is that the emergence of the cross-sectional psychopathological picture of the psychosis can be satisfactorily explained by the "intensity of traumatic experience," i.e., antecedent etiology. Because the subject matter of the psychosis is organized around the traumatic experience, the content, but not the form of the psychosis, should be comprehensible. The third essential characteristic of psychogenic (reactive) psychosis is goal-directedness. It is through this goal-directedness that the psychosis becomes an integral part of patient's life history.

There is no general consensus about the incidence of psychogenic psychosis. Strömgren (1968) estimates a morbidity risk (lifetime expectancy) of about 1%. He found that 10% of all and 15 to 20% of all newly admitted psychotic patients to the Aarhus Psychiatric Hospital in Risskov (Denmark), during the period from 1953 to 1968 belonged to the psychogenic group. On the other hand, Faergeman (1963) found that only about 2% of the patients admitted to the Psychiatric University Clinic at Copenhagen during the period from 1924 to 1926 were diagnosed as psychogenic psychosis.

On the basis of the clinical picture, Schneider (1927) separates psychogenic psychosis into three diagnostic groups, i.e., "emotional reactions" (approximately 65%), "disorders of consciousness" usually referred to as "dissociative-confusional states" (approximately 15%) and "paranoid states" (approximately 20%). Among the "emotional reactions," depression is the most frequent. In typical cases it is characterized by a passive attitude and lack of interest in the surroundings. However, atypical cases may occur. Included among the atypical cases are paradoxical reactions such as "funeral manias" (Hollender and Goldin, 1978) and "emotional paralyses," described by Baelz (1901).

Distinctly different from the emotional reactions are "dissociative-confusional" states with prevailing "disorders of consciousness" which in typical cases are manifested in the form of delirious reactions or clouded states. Included among the clouded states is the Ganser syndrome (Ganser, 1898, 1965) in which the flight from reality is goal directed.

The third group of psychogenic psychosis consists of "paranoid states." Among them the most frequently encountered is a "comprehensible paranoid reaction," the "sensitive delusions of reference" described by Kretschmer (1927, 1966, 1974).

While retaining the three forms of psychogenic psychosis, Pethö, Ban, Kelemen et al. (1984) divided psychogenic psychosis into two major groups. One with an acute onset consists of three subtypes: psychogenic regressive psychosis, psychogenic affective psychosis and psychogenic paranoid psychosis. The other with a subacute onset, psychogenic delusional development, consists of four variants: passionate (idealists, conjugal paranoia, erotomania), litigious (queruleous, reformatory zealotry), hypochondriacal (delusions of parasitosis, Shikano syndrome) and symbiotic (folie a deux, folie a trois). The psychogenic psychoses (regressive, affective and paranoid) yield to full remission with resolution of psychopathological symptoms usually within three months, but psychogenic delusional development has a tendency for chronicity and may result in transformation without disintegration of the personality. Prevailing characteristics of psychogenic regressive psychosis are clouding of consciousness and impaired orientation; of psychogenic affective psychosis, exaltation or depression; and of psychogenic paranoid psychosis, delusions of reference. In contrast to the acute forms, psychogenic delusional development is characterized by a logically derived systematized delusional system, which spreads within a restricted area.

It is assumed that it develops to a "key experience" in patients with paranoid personality traits.

It is commonly held that the form of psychogenic psychosis depends on constitutional factors. "Syntonic" or "extrovert" patients respond with an "emotional reaction," “hysterics" display a "dissociative-confusional state" and Schizoids" react with a "paranoid response." However, Strömgren (1958, 1968, 1974) maintains that more important than constitution is the nature of the traumatic experience. He suggests that emotional reactions are the result of simple situational conflicts, dissociative-confusional states are the outcome of a sudden disruption of patient's image of his environment and paranoid disorders are the consequence of a severe blow to one's "self-esteem" or to "one's self-image."

The question whether the three syndromes described are distinct diagnostic entities whether they are meaningful in terms of prognosis and/or treatment cannot be answered within a two-dimensional model of psychiatric classification. By employing a three-dimensional model, however, it was noted that the duration of illness was significantly different for the three acute psychogenic syndromes. Dissociative-confusional states last only from a few hours to a few days, emotional reactions (e.g., depression) from a few days to a few weeks and paranoid reactions from a few weeks to a few months.

Corresponding with the diagnostic category of "psychogenic psychoses" is the diagnostic category of "other nonorganic psychoses" in the ICD-9. This category is restricted to a group of psychotic disorders largely or entirely attributable to a recent life experience. Included in this category are nonorganic psychoses depressive type (reactive depressive psychosis, psychogenic depressive psychosis), excitative type, reactive confusion (psycho genic confusion, psychogenic twilight state), psychogenic paranoid psychosis (protracted reactive paranoid psychosis) and other and unspecified reactive psychosis (hysterical psychosis, psychogenic psychosis, psychogenic stupor). Diagnosis corresponding to "psychogenic delusional development" is not limited to "psychogenic paranoid psychosis" in the ICD-9 but includes "induced psychosis" (folie a deux, induced paranoid disorder) and other paranoid states (paranoia querulans and "Sensitiver Beziehungswahn").

Closest to the category of "psychogenic psychoses" is the diagnosis of "brief reactive psychosis" in the DSM-III. However, the diagnosis of "brief reactive psychosis" does not correspond with any diagnosis within the "psychogenic psychoses." The only correspondence between the two diagnostic systems relevant to psychogenic psychoses is the one between "psychogenic paranoid psychosis" and "acute paranoid disorder" of the DSM-III. Patients with "psychogenic delusional development" may be diagnosed as "shared paranoid disorder" or "paranoia" in the DSM-III.

In the treatment of psychogenic psychoses, antipsychotics are extensively employed. In spite of this, the fact remains that there is no convincing evidence, on the basis of properly designed and conducted clinical experiments, that they are therapeutically effective and/or superior to the benzodiazepines. Especially disappointing is the limited therapeutic responsiveness to antipsychotics in paranoid reactions. Apart from decreasing delusional dynamics, i.e., the force or intensity of the affective drive which accompanies the delusion, they have little effect on the content-disorder of thinking (systematized delusions).

While psychogenic paranoid reactions seem to persist in spite of the administration of antipsychotics, psychogenic dissociative-confusional states promptly remit in the course of administration of the same drugs. In view of the usually short duration (natural course) and reported therapeutic responsiveness of these conditions to barbiturate-induced abreactions (Sargant and Slater, 1963), it is difficult, in the absence of placebo-controlled experiments, to decide whether one is dealing with spontaneous remission or drug effects.

The situation is even more confounded in psychogenic emotional reactions. Because treatment with antidepressants does not seem to have satisfactory therapeutic effects (Bielski and Friedel, 1976), and antipsychotics may aggravate depression, as an ultimate resort not infrequently patients with psychogenic depressive (emotional) reactions are treated with electroconvulsive therapy.