Psychopharmacology and the Classification of Functional Psychoses
By Thomas A. Ban and Bertalan Pethö
Four-Dimensional Classification
Delusional Psychoses
Chronic Delusional Psychosis
"Imaginative psychosis" (Dupre and Logre, 1911), "intepretative psychosis" (Serieux and Capgras, 1911) and "hallucinatory psychosis" (Ballet 1913a,b; Ballet and Mallet, 1913) have also been described as subtypes of Magnan's (1886) "chronic delusional psychosis" (delire chronique a evolution systematique). In spite of this there are indications that acute and chronic delusional psychoses are distinct. This is best exemplified by the differential therapeutic response to antipsychotics in patients with acute (favorable response) and chronic (unfavorable response) delusional psychoses.
On phenomenological grounds, based on patients experience of their illness, Clerambault (1923) and Baruk (1959, 1974) differentiated two major groups of illnesses within the chronic delusional psychoses; one characterized by interpretative delusions and the other by delusions of passion. While Clerambault distinguished three subtypes of delusions of passion, i.e., erotomania, querulant delusions and delusions of jealousy, some believe that all three subtypes (and even delusions of passion) are parts of a syndrome referred to as idealistes passionne's by Dide (1913a,b). However, Clerambault and Lamache (1923) maintain that "erotomanics" are not true "idealistes" because their feelings of idealism are mixed with pride and fantasy or even with straightforward eroticism. Patients with "erotomania" are less spiritual and more carnal in their interests than Dide's idealistes passionne's.
There are distinct phenomenological differences between the two major groups of delusional psychoses with the essential difference being in that "interpretative delusions" constitute a passive-defensive experience with an insidious onset, while "delusions of passions" constitute an active-driving experience with an acute beginning. According to Baruk, patients with "interpretative delusions" live in a state of constant expectations. "His path seems to be beset by mystery, he is anxious, surprised and passive, questioning everything he sees, and seeking explanation which he only discovers gradually." Another important characteristic of patients with "interpretative delusions" is a feeling of suspiciousness. The whole personality is affected by the gradually widening, logically derived, consistently changing and progressive delusional system.
In contrast, patients with "delusions of passion" are constantly striving. They advance toward their goal with conscious and clear-cut demands from the outset. They are deluded only about their own desires while their thoughts are polarized in relation to their will power. Delusions of passions are characterized by emotional excitement (hypersthenic state), the quality of which may extend to the point of hypomania. Other distinguishing features include the "initial act of the will, the sense of purpose, the one dominant concept, the accompanying vehemence, the fact that patient's ideas are fully formed from the start, and the claims made on other people" (Baruk, 1959).
Among the three subtypes of delusions of passion, "erotomania" is encountered in both acute and chronic forms. However, even if encountered as an acute syndrome, "erotomania" shares common characteristics with "chronic delusional psychoses" in a relatively unfavorable therapeutic response to antipsychotic drugs.
Although the term "erotomania" or "amorous delusions" was used by Esquirol (1838), it was Clerambault and Lamache (1923) who employed if first for designation of a specific clinical syndrome which develops in two stages, i.e., a phase of hope, followed by a phase of resentment. At the core of erotomania is the belief that the person on whom the patient is fixed (referred to as the "desired object") is in love with the patient and consequently it is not the patient but the "desired object" who has made the "initial advances." The patient believes that the "desired object" is single or not properly married, and even more important, cannot find happiness and be a complete person without the patient. From these "fundamental postulates" a continuous vigilance and/or protection of the "desired object" follows with indirect conversations with the "object." The patient pursues the "desired object" by any and all means and none of the "paradoxical and contradictory behavior" of the "desired object" modifies the strength of the delusions.
Distinctly different from "erotomania" or "the fantasy lover" is "delusions of jealousy." One of the prototypes is the husband who becomes more and more convinced about his wife's infidelity and whose ideas at a certain point reach delusional intensity. The helpless spouse is interrogated unceasingly and may be kept awake for hours at night; has under- clothes searched for stains of semen; and her vaginal moisture is "pieced together" in "evidence" of "frequent sexual intercourse with someone else" (Fish, 1974).
The third subtype of "passionate delusions" are "querulant delusions" first classified by Beer in 1869 and specially studied by Krafft-Ebing (1879). According to Baruk (1959) patients with this clinical syndrome "indulge in a host of claims, legal proceedings and complaints lodged with the authorities." Closely related to the "querulants" are the "litigious" patients and closely related to the "litigious" are the "hypochondriacal psychogenic claimants." While the "litigious" patient undertakes a series of lawsuits, the first leading to others, the "hypochondriacal claimant" reproaches the doctor for not having cured him or even for giving him some harmful treatment.
In some instances delusions of passion are centered either on religious or philosophical themes or on political ideas. Considering the common characteristic of these patients Dide (1913a,b) refers to them as idealistes passionnes and perceives them as a distinct diagnostic group. Regardless, however, of the topic (content) of the delusions, patients with "delusions of passion" constitute a dangerously violent diagnostic group. The problem is compounded by limited success with different treatment approaches including antipsychotic drugs. In spite of the commonly held belief that diphenylbutylpiperidines such as pimozide are superior in their therapeutic effect to other psychotropic drugs, because of their greater specificity for the DA2 receptors, there is no evidence on the basis of properly designed clinical experiments that any one of the antipsychotic drugs is superior to another in this diagnostic group.