Psychopharmacology and the Classification of Functional Psychoses
By Thomas A. Ban and Bertalan Pethö
Four-Dimensional Classification
Functional Psychosis: Reactive vs Endogenous
There are at least two distinct populations in functional psychoses. One population is conventionally referred to as autochthonous or endogenous psychosis and the other as reactive or psychogenic psychosis.
In spite of the controversy regarding both terms, i.e., endogenous and psychogenic, there is a general agreement that psychic reactions arising from conflictual experiences and external events are exogenous (although the term is usually retained for the psychosis resulting from an exogenous biological reaction and the psychosis associated with "coarse brain disease"). Phases and processes arising from inner causes without an external event are endogenous (Jaspers, 1963). Within this frame of reference, the concept of endogenous psychosis -- which, according to Pichot (1983), has its origin in Morel's (1857, 1860) teachings -- implies an innate genetic biological defect, while the concept of psychogenic or reactive psychosis implies the presence of a psychic trauma, regardless of whether it is the result of a conflictual situation or a life event. Accordingly, in case of endogenous psychosis the psychosis cannot primarily be attributed to an exogenous factor (life event) even if exogenous factors play a precipitating role, while in case of psychogenic (reactive) psychosis the psychosis cannot exclusively be attributed to an endogenous factor, even if endogenous factors play a predisposing role.
The concept of psychogenic psychosis has evolved through the work of the Danish psychiatrists Wimmer (1916), Faergeman (1945, 1963), Strömgren (1968, 1974) and Retterstal (1978). In the development of the concept, Jaspers (1913a,b) definition of "pathological reaction" played an important role. According to Jaspers, to fulfill the criteria of "pathological reaction" there must be an adequate precipitating factor, standing in a close time relationship with the reactive state. There must also be a meaningful connection between the content of the experience and those of the abnormal reaction; and reversibility, i.e., disappearance of the abnormality when the primary cause for the reaction is removed. In this respect pathological reactions contrast with morbid processes which appear spontaneously. Furthermore, Jaspers suggests that reactive states can be classified in at least three different ways, i.e., according to what precipitates the reaction, according to the particular psychic structure of the reactive state and according to the type of psychic constitution that determines the reactivity. Hoenig (1985) maintained, however, that Jaspers was interested in “pathological reactions” only from a methodological point of view and did not consider “psychogenic psychosis” a nosological entity in spite of his contributions to its conceptual development.
In his classic monograph Wimmer (1916) defined psychogenic psychoses as “clinically independent psychoses” caused by “mental trauma” acting on a predisposed foundation.” Furthermore, he suggests that its two essential components, i.e., predisposition and mental trauma, determine the “moment for the start of the psychosis, the fluctuations of the disease, and very often also its cessation.” On the other hand, Wimmer contends that “the form and the content of these psychoses are more or less directly completely (comprehensibly) determined by the precipitating mental factors.” Psychogenic psychoses almost always end in full recovery. If this is not the case the diagnosis may need to be changed.
Important contributions to the understanding of psychogenic psychosis were made by Strömgren (1968,1974) and McCafe (1975). For Strömgren these psychoses are psychogenic in the sense that “the mental trauma must be of such a nature that the psychosis would not have arisen in its absence.” There must be a close temporal correlation between the onset and the traumatic experience. There is a relationship also between the traumatic situation and the course of the psychosis. This is to the extent that “if the situation ceases to exist the psychosis will usually stop immediately.” But even if the situation persists, according to Strömgren, “the psychosis will not go on forever.” Furthermore, he asserts that “it is not the objective force of the trauma which determines the reaction of the patient,” but rather “it is the subjective experience determined by the special sensitivity of the patient at the moment of the trauma.”
Insofar as the "etiology" of psychogenic psychosis is concerned, Strömgren divided the exogenous traumatic factors into five groups, i.e., experiences of an entirely impersonal character, social disasters, conflicts within the family, isolation and inner conflicts. He maintained, however, that "on the whole one cannot expect to find a clear correlation between the quality and the quantity of the trauma and the type or extent of the patient's reaction." This implies that much depends on the special sensitivity, i.e., "catathymic predisposition" of the patient, which in turn suggests that endogenous factors possibly play a predisposing role. In favor of this contention are the relatively uniform genetic findings that patients with psychogenic psychosis have a high incidence of "mentally abnormal subjects" in their families.
Taking all these factors into consideration Pethö, Ban, Kelemen et al. (1984) suggest that in "psychogenic psychosis" the onset of psychopathology must be attributable beyond reasonable doubt to a precipitating life event. Psychotic content must be fully understandable with respect to the precipitating life event and/or on the basis of patient's life history and/or personality. The psychosis must appear as an integral part of patient's life history. In addition, in psychogenic psychoses the intensity of the traumatic experience should sufficiently explain the emergence of the psychosis. There should be thematic continuity between the traumatic experience and the psychotic content; and there should be a meaning to the psychosis appropriate to the situation with manifestations such as theatricality and protest directed towards the onlookers. To prevent overlap, the absence of certain endogenous psychopathological symptoms, such as inhibited thinking, tangential thinking, flight of ideas, perseveration, neologisms, blunted affect and/or autistic behavior is a prerequisite for the diagnosis of psychogenic psychosis.
Today psychogenic psychosis is recognized in many countries including Denmark, Norway (reactive psychosis: psychogenic and constitutional), France (psychoses reactionelles) and the USSR (reactive psychosis) (Giljarovski, 1960; Widlocher, 1958). There is probably also some overlap between psychogenic psychosis and Kasanin's (1933) schizoaffective psychosis and Staehelin's (1946/47) schizophreniform affective psychosis (schizophrenieahnliche Emotions- psychosen) described in details by Labhardt (1963).
The diagnosis of endogenous and reactive (psychogenic) psychoses, similar to the distinction between functional and organic psychoses, can be made only within a two-dimensional model. Cross-sectional psychopathological symptom profiles should be supplemented with information on the form of onset and antecedent-etiologic event(s), e.g., psychological factors such as death of a beloved relative or retirement, for the interpretation of findings. Accepting endogenous and reactive psychoses as end-points divides the functional psychotic population into two major groups and only in one of these two (i.e., endogenous psychosis) is treatment with antipsychotic drugs the primary choice. In reactive psychosis, treatment with antipsychotics usually does not suffice and should be combined with or substituted by other therapies.
In addition to the differential therapeutic response between the two populations, patients within both populations show a differential therapeutic response to antipsychotic drugs. Because a differential therapeutic response indicates biological heterogeneity, the findings of differential therapeutic responses within both populations is in line with the contention that both endogenous and psychogenic psychoses consist of more than one diagnostic group.