Psychopharmacology and the Classification of Functional Psychoses 

By Thomas A. Ban and Bertalan Pethö

Four-Dimensional Classification

Delusional Psychoses

Delusional Development

The concept of delusional development dates back to the Tubingen school of psychiatry and the work of Gaupp (1914a, b, 1938, 1974a, b) who in his articles on the mass murderer Ernest Wagner, made the first attempt to demonstrate that paranoid psychoses are not always endogenous, i.e., the result of an intruding "process" of inner origin. According to Gaupp some delusional psychotic developments are "understandable psychologically" and can be viewed as developmental anomalies that are the "direct result of experiences in persons with an abnormal psychopathic personality." Gaupp's concept was further elaborated by Kretschmer (1927) who put forward the notion that paranoid psychoses, which he referred to as "the sensitive delusions of reference" (Die sensitive Beziehungswahn) are understandable developments of sensitive personalities. For Kretschmer the term "sensitive" implies sensitiveness about one's own shortcomings (regardless whether social, physical or psychological) to the extent that it interferes with one's success. A common characteristic of sensitive personalities is the coexistence, i.e., simultaneous presence of conflicting traits, such as gentleness, softness, sensitiveness and excessive vulnerability on the one hand and assertiveness, ambitiousness and stubbornness on the other. According to Kretschmer, it is in such a person that a full-blown paranoid psychosis may develop in reaction to a key experience (that exposes patient's weakness). Kretschmer placed special emphasis on the personality type that he considered to be on a continuum from the normal through abnormal to psychotic, in the development of paranoid psychosis. Thus, in Kretschmer's conceptual framework there is a quantitative but not a qualitative difference between a normal subject and a psychotic patient.

Kretschmer's typology served as a reference point to the work of Sheldon and Tucker (1940) in the United States; and his concept of the "sensitive delusions of reference" was adopted in France where according to Pichot (1983) "it was even more successful than in its country of origin." Nevertheless by the late 1960s the trend was reversed. With greater recognition of a qualitative difference (i.e., contiguity) between the thinking of non-psychotic subjects and the thinking of psychotic patients, it has been recognized that "understanding" the meaning of a delusional state is not possible. In Gruhle's (1915, 1936) words: "A delusional state does not arise from subliminal wishes or from certain suppressed movements of the mind," but it is the production of cerebral pathology "which cannot be derived from and grasped by intuition."

There is now substantial evidence that "delusional development" is distinct from psychogenic paranoid psychosis in terms of the role of the identifiable trauma, and/or the time relationship between the precipitating trauma (if present) and the manifest syndrome which is characterized by a logically derived systematized delusional system. In this respect the paranoid psychosis of prisoners and deaf people is closest to delusional development. Other delusional developments include the syndrome of Allers, monosymptomatic hypochondriacal delusions and induced psychosis, also referred to as symbiotic or shared paranoid psychosis (Strömgren, 1968). The essential feature of the latter is a delusional system, usually persecutory, that develops as a result of a close relationship with another person who already has a disorder with the same or similar delusions.

Other features, distinguishing delusional development from psychogenic paranoid psychoses, include the tendency for chronicity and for transformation of personality.

The diagnostic concept of delusional or paranoiac development has received support from Berner (1965) who, on the basis of the results of his follow-up study with paranoiac patients, was able to formulate criteria for the separation of patients with schizophrenic and affective psychoses from the core group. Berner's criteria have received further substantiation in the Lausanne survey of the same patients by Muller (1981). It, therefore, seems that the diagnostic concept of paranoiac or delusional development is valid and the diagnosis of paranoiac development is distinct from that of schizophrenic or affective psychoses.