Psychosis

Diagnosis and definition

Therapy and prevention

Social and legal aspects

Research

BIBLIOGRAPHY

It is a generally accepted statistic that about half of all the hospital beds in the United States are occupied by psychiatric patients. Since neurotics are rarely hospitalized, one can define the public health aspect of the problem of the psychoses simply by saying that psychotics occupy about half the beds of the nation on any given day. Approximately half of these beds again are occupied by people diagnosed as suffering from schizophrenia, the major so-called functional psychosis. The majority of the remaining psychiatric beds are occupied by those with a variety of organic psychoses, predominantly aged people suffering from senile or arteriosclerotic psychoses. From the standpoint of the numerical significance of the problem alone, psychoses merit major interest. If one keeps in mind that schizophrenics are likely to become incapacitated early in life, with the mean onset occurring between 20 and 30 years of age, the problem gains in importance. Although the average length of hospitalization of psychiatric patients decreased by 10 per cent between 1954 and 1964, the number of admissions per year nearly doubled during that period.

Statistics, of course, are only a small part of the problem. They do not tell about the immense human suffering involved in psychoses, nor do they picture the fascination which the topic has aroused from time immemorial. By and large, the term “psychosis” is used as an equivalent of “a major psychiatric disorder,” with all the limitations of any such generalization. It has been equated with being possessed by spirits or by the devil, as well as, on the other hand, being revered as a manifestation of divinity. It is also often referred to as “craziness” and is considered by many as a profound revelation of all that goes on in the deep recesses of the human mind.

The fact is that most American clinicians today do not consider a person suffering from a psychosis (a psychotic) to be basically or qualitatively different from so-called normal people. These psy-chotics may be quantitatively different. They presumably are less able to keep the “deeper” layers of their minds (the primary process) from showing in their daily activities; in some ways, then, they may be more profoundly human.

If one would make a tentative and very limited attempt at defining psychosis, one would have to say it refers to a major psychiatric disorder, one aspect of which is usually some obvious conflict with reality, or a difference from the way a majority of the population perceives reality, or a difference from the expected cultural norms concerning behavior. In the first place, this definition alone makes quite clear that there are areas for disagreement. Not everyone showing such difference or conflict is psychotic. Furthermore, not all people considered psychotic by specialists are necessarily manifestly disturbed in the ways mentioned— either in those actions which are to their own detriment or in those detrimental to society. During most of their lives they may show no obvious sign of any major disorder at all. It may either erupt suddenly or make itself felt only latently and subtly, or be disguised in culturally acceptable forms, such as religious or political fanaticism.

The fact that abnormal behavior of psychotics involves social and cultural norms makes it quite obvious that psychoses are an appropriate concern of such social sciences as sociology, cultural anthropology, and social psychology, and also of allied fields such as jurisprudence and criminology. What is more, psychotic manifestations are also clearly influenced by cultural factors. This holds true not only for different cultures and subcultures but also for temporal changes—for example, within Western culture. What used to be thought possession by the devil has become paranoid ideation involving electric influencing machines, radio, television, radar, or electronic snooping devices.

The etiology of psychoses also spans the physical sciences and the social sciences, and there has been much argument over the primacy of organic or “functional” (often equated with psychogenic) causes of psychoses.

The American Psychiatric Association (1952) categorizes psychotic disorders as follows:

Involutional psychotic reaction

Affective reactions: manic-depressive reactions (manic type, depressed type, other), psychotic depressive reaction

Schizophrenic reactions: simple type, hebephrenic type, catatonic type, paranoid type, acute undifferentiated type, chronic undifferentiated type, schizo-affective type, childhood type, residual type

Paranoid reactions: paranoia, paranoid state

Diagnosis and definition

Psychiatry does not abound in operational definitions, and the term “psychosis,” unfortunately, provides no exception. Definition and diagnosis are often closely related in medicine. Therefore, we can say that traditionally and clinically, a patient was diagnosed as psychotic by some simple clinical rules of thumb—if there was a disturbance in orientation regarding time, place, and person; if affect was not appropriate; if the thought processes were found not to be intact (not coherent, relevant, and connected); if the memory of recent or past events was disturbed; if the behavior was inappropriate or obviously influenced by delusions and hallucinations.

This definition includes, of course, both organic and “functional” psychoses. With regard to these terms, there are some more subtle problems of definition, for there are traditionally two basic schools of thought: (1) that psychotics are qualitatively different from nonpsychotic people; this concept is held primarily by those who see schizophrenia or other “functional” psychoses as diseases with a clear-cut somatic matrix; (2) that psychotics in general, and schizophrenics in particular, are only quantitatively different from nonpsychotic normal personalities. Adolf Meyer, pioneering the concept of psychobiology, formulated the concept of psychotic reaction types in keeping with the idea that psychoses are a variation of ordinary “reaction types.” Most of all, the psychoanalytic school of thought comprises psychoses within its general theory of personality. Neither school of thought necessarily excludes organic etiologic factors.

Certainly, black-and-white thinking about the concepts “organic” and “functional” seems to be outdated, although the journals hardly reflect this fact. Furthermore, one of the difficulties with the classical scheme of static classification of psychoses is the fact that so many labels are obviously artificial. For, to the chagrin of clinicians, patients often do not seem content to stay in an assigned group, and not only overlap symptomatologically but tend to behave in such a way as to lead clinicians to change their diagnosis of manic-depressive psychosis to schizophrenia, and occasionally vice versa. What is more, diagnoses such as puerperal psychoses, involutional psychoses, arterio-sclerotic and senile psychoses often are hardly more than superficial labels. In many patients labeled “psychoses with arteriosclerosis,” one is hard put to find evidence of arteriosclerosis, or at least more arteriosclerosis than is found in people of the same age group who are not so diagnosed in vivo or post mortem. In many of these patients, symptoms, character traits, and fragile defenses seem to have been present long before pregnancy, involution, or old age; and the best one can surmise is that the advent of any of these events— hormonal changes, psychological trauma, decreased oxygenation due to an aged circulatory system, decreased social usefulness and esteem— has finally either added the necessary strain or has decreased the integrative capacity, thus producing the change from the latent to the manifest disorder. [SeeAging, article onPsychological Aspects.]

A useful definition—and theory—of psychosis has to accommodate all these observed clinical facts and allow for forces of primarily somatic and primarily experiential factors to play their roles singly and in combination, on different levels of interaction: molecularly as well as grossly (for instance, in the case of bacterial or physical trauma), psychologically as well as sociologically and anthropologically.

In my own thinking, it appears that a unified theory of psychosis can be formulated that integrates the organic and the experiential vantage points and offers many advantages.

The conceptual framework, as suggested before, would be that of psychoanalytic ego psychology. The manifestation of any psychosis with any etiology could then be described and understood in terms of changes in ego functioning within a given cultural setting. For this purpose, psychosis is seen as a behavioral syndrome, not a single disease. The somewhat variable symptoms generally associated with this diagnostic label must be understood as the final common path of a number of conditions which may lead to, and manifest themselves in, a severe disturbance of the ego. These conditions may range from a relatively purely psychogenic (experiential) weakness of the ego to afflictions of ego functioning caused by disturbances brought about by infections, by arteriosclerotic, enzymatic, or toxic states, or by traumatic, constitutional, or genetic factors: in short, by any number of chemogenic, histogenic, genogenic, sociogenic, or psychogenic factors, or by any combination thereof. While an outstanding somatic factor may be present, usually this must be accompanied by some psychological predisposition (in terms of ego patterns) to produce the psychotic picture. Conversely, certain somatic factors are probably secondarily brought about by the psychogenic etiology of psychosis, at least for those cases of early onset and severe outcome.

In brief, the multiple-factor, psychosomatic theory of psychoses permits one to understand psychosis as the common result of a variety of individually differing etiologic factors. It enables one to make a prognosis on the basis of a careful study of the specific etiology involved in a specific case, and permits optimal therapeutic control of the highly individual constellation of forces resulting in the manifestly common path of the syndrome, by directly or indirectly, somatically, psychologically, or environmentally, producing better ego functioning.

Patterns of ego functions and disturbances

Psychoanalytic theory is predicated upon propositions concerned with the dynamic interaction of environmental and organismic (maturational and congenital) forces with learned responses. Character and personality can thus be understood as patterns of compromise, as resultants of a field of diverse forces. Ego functioning, more specifically, must be described in terms of its pattern: While it may be rather uneven—one ego function may be “better” than another—and the blend ultimately unique, each given pattern may be classified roughly under diagnostic or descriptive headings.

Inasmuch as assessments of the degree of functioning are involved in descriptions of patterns of ego functioning, quantitative assumptions cannot be avoided. Psychoanalytic theory includes many quantitative statements, as might be expected in a theory in which concepts of force and economy play leading roles. The entire concept of libidinal cathexis in object relations and internal representations is, of course, a basically quantitative one.

However, psychoanalysts generally have not addressed themselves to attempts at precise quantification. It should be possible, though, to adapt the experimental methods of measurement to psychoanalytic variables.

Meaningful methods of measuring ego strength are possible if ego strength is defined as “the totality of the ego’s capacity to perform its many functions.” Each individual ego function could be quantitatively assayed, given a weighted score, and combined into a total score, much as the IQ is arrived at in the Wechsler-Bellevue Intelligence Test. Also, ego strength must be viewed globally, very much like Wechsler’s view of intelligence (1939). The ego cannot be conceptualized as a perfect sphere, of course, with each area of ego functioning constituting a radius, nor can it even be compared in this context to the segments of an orange. The image that suggests itself is that of an uneven raspberry on which each surface point constitutes the terminus of one of the many ego functions. Furthermore, this protean raspberry might be made of stretchable rubber which would change its shape developmentally and would be subject to momentary and daily variations.

Table 1 presents some important groups of ego functions and disturbances.

Multiple-factor theory

The concept of psychoses as disorders that have many different etiologies but share a final common path of ego disturbance leads quite logically to the concept that the diagnosis of psychosis at present can best be made on the basis of the degree of ego disturbance in a given patient. It also follows that the degree of ego disturbance that we are willing to call psychosis is based on rather arbitrary decisions.

As mentioned, there are variations of ego functioning in every person—that is, healthy people exhibit certain ego functions which are of a very high quality and others which are less so. It is probably true that a surprising number of ego disturbances, sometimes of considerable severity, appear in a large number of people who are generally considered normal statistically and in terms of lifelong functioning. These are still “normal” people, however, by virtue of the fact that the ego disturbance occurs in a relatively small segment of their personality or one which, in their particular setting, does not crucially interfere with functioning. A fear of deep water, for instance, is not likely to be a vital disturbance in an inland state such as Kansas. Obviously, forms and expectations of ego functions will vary culturally.

Also, one may find, on taking a careful life history, that there was some episode in ego disturbance at a certain age which, although fairly severe, was self-limited and had no further consequence. Chance is involved in such matters: a marked disturbance in military service may become a matter of troubling public record and later secondary pathology; some private disturbance may forever remain unknown and become a subject of amnesia.

Under certain conditions, e.g., those of extreme deprivation, some delusions or hallucinations (of food, water, companions) must be considered virtually as adaptive functions of the ego which usually promptly disappear when the emergency does; they may in fact have definite survival value during the emergency: for example, they may bolster the person with the irrational feeling that a special deity is guarding him and with the certainty that all will be well. Then there are, of course, a wide variety of neurotic ego disturbances that must be considered. All these facts will serve to highlight further the difficulties in forming a diagnosis of psychosis on the basis of one specific syndrome.

It is to be remembered that from a theoretical viewpoint we postulate that psychosis is not one condition, not one point on a continuum of ego strength, but a range along a continuum: within a group diagnosed as psychotic one could classify those who are sicker and less sick, patients with more and less over-all ego strength (also varying ego strength in different areas at different times). In this sense ego functioning not only must be seen as a quantitative proposition but also must be viewed as greater or lesser in different areas at different times.

It is useful to remember that, in essence, the diagnosis of psychosis is a phenomenological diagnosis predicated upon the observable failure of ego functions (including reported ones, of course), rather than upon assumptions concerning dynamic structure or other criteria.

The diagnostic continuum. Psychosis can be conceptualized as ranging at the low end of the continuum of ego strength, while normality covers a range at the other end. Presumably, schizophrenia, manic-depressive psychosis, obsessive-compulsive neurosis, severe character disorders, phobias, anxiety hysterias and neuroses, and hysterias lie approximately in that order, reading from left to right, between these two points. Figure 1 depicts this continuum. However, this traditional viewpoint is of limited value, since each of these conditions is characterized only by a symptom picture that expresses a single outstanding defensive compromise formation. There can be no question that a severe hysteria may involve a weaker ego and may

be a condition relatively closer to a psychosis (schizophrenia) than to a mild obsessive-compulsive disorder or a circumscribed phobia.

A psychosis may sometimes be difficult to diagnose in its early stages because the clinical picture may involve a vast variety of patterns of ego functioning. These might, of course, also be present in neurosis, circumscribed neurological disorders, character disorders, psychopathic (sociopathic) personalities, perversions, and other disorders, and the psychosis may overlap with them.

It is not the intention here to discuss in detail the clinical problems of differential diagnosis but, rather, to attempt a conceptual clarification: the clinical diagnosis of early psychosis must be predicated upon the judgment that the degree of ego disturbance is so severe and the defenses so pathological that one may expect the development of a full-blown psychosis if there is no skilled intervention.

Just as there are many varieties of full-blown psychoses, so there are many forms of early psychotic symptomatology. Sociopathic irresponsibility is indicative of poor integration of the superego and poor frustration tolerance; poor reality testing and poor object relations (by the ego) may occur in a person previously conscientious, polite, and kind to children and animals. Thus tabloids frequently print lurid accounts of choir-member offspring of pillars of the community who, apparently, suddenly become psychotic and commit criminal acts. Yet it is quite possible that signs of disturbance had been present for a long time. Seclusive-ness, as well as sudden extreme “extroversion,” may be a first indication of a psychotic break. Lability of mood often signifies impaired control.

Nor are the specific manifestations of ego disturbance the only prodromal signs of psychosis: the prepsychotic personality may be sociopathic, infantile (little control, many pregenital drives), brilliantly high-strung (artistic or intellectual achievement at the cost of other development), excessively religious (i.e., a reaction formation to poorly controlled hostility), dull and apathetic (because of early disturbance of autonomous functions and object relations), or have poor achievement (because of preoccupation with fantasies, etc.), despite high intelligence.

A good account of the great variety of full-blown psychoses has yet to be written. In essence, one psychotic may differ almost as much from another as any individual may differ from another. There are those who never progressed, and those who regressed from the highest levels of achievement; those who are obviously bizarre and hard to empathize with, and those whom one is likely to consider less disturbed than they actually are because of a good facade. Some psychotics are very kind; others are cold and sadistic. Some are very productive and sensitive; others are seemingly without drive or ability. Psychotics have been unjustly downgraded and romantically overestimated as artists, intellectuals, or, as some would have it, revolutionaries whom society of necessity secludes. It is easier to be categorical about psychotics if one does not have too much understanding and knowledge of them.

Differential diagnostic concepts

In the diagnosis of psychosis a number of diagnostic labels of secondary order are frequently used, sometimes in unclear and confusing ways.

Borderline psychosis. Borderline psychosis can be quite accurately defined as a condition of ego strength and personality functioning which lies on the continuum between a psychotic and a neurotic condition. In an appraisal of the ego strength of such a patient, one finds that thinking, affective control, perceptual reliability, and object relations are all of questionable soundness without being quite disturbed enough to merit the diagnosis of psychosis.

The diagnosis of borderline psychosis is indicated if the condition described refers to an apparently stable condition of functioning, perhaps even a lifelong one, without signs of progressive deterioration. In that sense, “borderline” is identical with the term psychotic character, and it relates to a character formation with many unfortunate defensive traits that are likely to make a person appear quite peculiar (even though he may often be quite brilliant and useful in isolated areas) without his ever developing a frank psychosis.

Incipient psychosis. If the picture of dubious functioning described as borderline psychosis is present and is accompanied by signs of increasing lability of mood, progressive inability to control impulses, increasing emergence of the primary process, and increasing crumbling of defenses, with deja vu experiences, feelings of unreality, impaired sleep, impaired appetite, and a rising anxiety level, then we are dealing with incipient psychosis, and steps must be taken to avoid its further progress.

This discussion implies quite clearly that in diagnosis it is important to judge not only the nature of functioning and the quality of the defense patterns but also the stability of the defensive patterns. Clinical experience permits little doubt that many people arrive at certain character formations— more or less pathological or normal—which they maintain all their lives. Not only do some people remain “borderline” all their lives, but some psychotics remain stabilized at certain levels of illness and do not regress further; others do regress. Some psychotics have four, five, or more episodes during their lives which always take the same form and which then show spontaneous remission. And some people have character peculiarities—psychotic or otherwise—which are lifelong, without any progression or regression of note. Clinical experience suggests the hypothesis that each person has a certain amount of ego strength—or, more specifically, strength of the synthetic functions of the ego—and this very often involves the stabilizing at a certain level of pathology, below which a person does not go under ordinary or possibly even extraordinary life circumstances.

Potential psychosis. Potential psychosis seems a useful diagnosis if one can observe poor ego functioning together with defenses that could eventually lead to a psychosis. That is, one might note the same symptoms that occur in borderline conditions, but accompanied by less stability in the defensive pattern. In the potential psychotic one may note previous episodes of increasing precariousness of balance between drive and defense, with outstanding defenses of denial and projection, and signs of loss of perceptual and motor control. In other words, the diagnosis “potential psychosis” may be useful to connote a condition ranging between “borderline” and “incipient,” that is, more labile than the former and less labile than the latter.

Latent psychosis. The designation “latent psychosis” might be employed when there is evidence of an existing psychosis which is, for practical purposes, covered up most of the time: i.e., in psychotherapy one might see that somebody is usually under the influence of primary process thinking and constantly beset by severe distortions of reality, but he manages to keep all these problems private by the use of intelligence and clever rationalizations. Such a person requires a favorable environment in order to continue to appear manifestly normal. Usually a forced change in environment or a change in living circumstances will suddenly disrupt the delicate arrangement; the patient will then surprise the world with the emergence of full-blown delusions of obviously long standing. The concept of latency thus refers in essence to the social impression which this individual makes. This nonpsychotic impression may also prevail in an ordinary clinical examination if the patient feels uncooperative, but it is extremely likely to appear in projective and other diagnostic testing, and in prolonged psychoanalytic interviews.

Therapy and prevention

The problem of a systematic and effective therapy for the psychoses is, of course, related to the matter of etiology: one usually wants to affect the causes of a disturbance. Since there is no general agreement on the causes of the “functional” psychoses and even very little on the etiology or pathogenesis of the organic psychoses, e.g., the so-called arteriosclerotic or senile psychoses, there is not much consensus about therapy for any of them.

If one accepts the proposition that there are multiple etiologies, it follows that one must attempt to treat each patient as much as possible within the individual constellation of causative factors.

A few therapies enjoy particularly widespread usage. Of the “shock treatments,” insulin therapy has lost the importance it had in the decade after World War II, but it is still used in some cases of schizophrenia. Its relative expense in terms of personnel and the need for considerable experience essential for its use are responsible in part for its decline. Electroshock therapy, or, as it is more often called, ECT (for electroconvulsive therapy), at first replaced insulin treatment to a large extent both for schizophrenia and, especially, for depressions. In turn, it lost popularity with the development of psychotropic drugs in the 1950s. By 1965 the tide seemed to have turned to a certain extent. The anti-depressants, for instance, have not proved miracle drugs after all, although undoubtedly they are often clinically useful (Cole 1964). ECT has been greatly refined by use of intravenous anesthetics and muscle-relaxing drugs, obviating the panic some patients felt and the danger of fractures. [SeeElectroconvulsive Shock; Mental Disorders, Treatment Of, article OnSomatic Treatment.]

The psychotropic drugs were the most important therapeutic modality in the mid-1960s. Popularly, the “tranquilizers” are most widely known and, among them, especially the phenothiazines. There is little question that the psychotropic drugs have changed much of psychiatric practice, for they often decrease or remove psychotic symptoms, make disturbed patients behave without violence, and decrease panic, delusions, and hallucinations. Thus, state hospital stays have been decreased, rehabilitation is markedly helped, and hospitalization in general hospitals is made possible.

Nevertheless, the psychotropic drugs are by no means curative, nor is their over-all effectiveness proved beyond doubt or the mode of their beneficial effect agreed upon. Empirically, however, they seem to create at least the conditions in which other therapy, spontaneous improvement, or at least socially acceptable behavior is possible for many psychotics who could not profit similarly without them.

As in all therapy, controlling variables other than the therapeutic agents, providing comparable groups of patients, and ruling out the effect of time alone are very difficult. The most promising development might well be Chassan’s development of the intensive design (Chassan & Bellak 1966). [SeeDrugs, article onPsychopharmacology.]

Social aspects of therapy have found their expression especially in community psychiatry (Bellak 1964). Keeping the patient close to home and providing early treatment in community clinics and follow-up in the community after a rather prompt hospital discharge play a marked role. Rehabilitation programs, as well as group therapy and family-centered therapy, play an often-constructive role.

The psychotherapy of psychoses plays more of a role for the extramural patient, if for no other reason than that the large state hospitals still rarely have enough staff for it. In clinic and private office practice, however, it often leads to empirically satisfying results. The adjunct treatment, by drugs, milieu therapy, and other measures, is becoming more popular.

For some of the organic psychoses, such as acute alcohol psychoses, there are specific, somatic treatment forms.

It is difficult to generalize about the effectiveness of treatment of psychoses as a group. In the case of an acute schizophrenic or depressive psychosis, it is not unusual today that as high as 80 per cent of all first admissions to a therapeutically active hospital may be discharged within 30 days. On the other hand, for about 7 per cent of all schizophrenics, the length of hospitalization still remains 20 years.

Primary prevention in the public health sense is also closely related to concepts of etiology. Since even most geneticists admit the significance of environmental factors at least for the manifestation of latent liabilities, and hardly anybody doubts the effect of experiential factors, a great deal more could be done for prevention of psychoses by public education, psychiatric well-baby clinics, and, where need be, legislation concerning the disposition of children with unsuitable parents, or whose parents are divorced or otherwise separated.

Secondary prevention, by early treatment of incipient disturbances, is making progress by virtue of greater federal and state investment in community mental health. Similarly, tertiary prevention (of chronicity) by rehabilitation is in the process of development.

Social and legal aspects

As long as psychotics were considered to suffer from a disease, they were usually studied as individuals in isolation, as it were. With an increasing awareness of the importance of interpersonal relationships, both the genesis and the cause of psychosis in relation to social interaction have attained more importance. Also, the ward setting and its effect on psychoses have been described by Stanton and Schwartz (1954), and social and epidemiological aspects of psychoses have been formulated by Hollingshead and Redlich (1954), Faris and Dunham (1939), Lemkau and Crocetti (1958), and others. The differing patterns in the family structure, especially of schizophrenics, have been discussed, e.g., by Opler and Singer (1956) and Sanua (1963). [SeePsychiatry, article onSocial Psychiatry.]

Because of the impairment of judgment and the lack of impulse control in many psychotics, and the occasional commission of crime by psychotics, special social-legal problems exist with regard to the involuntary commitment of the mentally ill to hospitals and the observation of their constitutional rights under such circumstances. Furthermore, the specific problem of legal responsibility for crimes has to be considered [Roche 1964; see alsoPsychiatry, article onFORENSIC PSYCHIATRY].

Research

Research in psychoses has suffered greatly from a lack of conceptual clarity. And a lack of methodological sophistication among clinicians who usually engaged in research only as a by-product of clinical and therapeutic work has bedeviled the field. As examples one might mention the tremendous popularity of Kretschmer’s morphological classification (athletic, asthenic, pyknic) and the complete absence of valid supporting data for it from controlled studies. The same can be said for the welter of genetic studies: if anywhere there are diagnoses of family members which have been made under blind, controlled conditions so as to avoid contamination of diagnostic judgment of the incidence of psychoses in the relatives of the patient (as compared with a control group), I have never run across them. As Tienari points out (1963), most of the genetic studies have been particularly poor methodologically. [SeeMental Disorders, article onGenetic Aspects; Psychology, article onConstitutional Psychology.]

There are some methodologically sophisticated studies by social scientists and by physicians with training in the various medical and basic sciences. These researchers do not usually have clinical psychiatric experience and are rarely psycho-dynamically trained. Rather than cast aspersions on their undertakings, one simply has to acknowledge that psychoses are protean manifestations of all facets of human life and that research has suffered from the fact that it is difficult to marshal all the knowledge and experience needed to deal with the many facets involved.

There is no bodily system or organ which has not been more or less extensively implicated in the cause of psychoses, especially of schizophrenia (Bellak 1948). Psychoanalysts and psychologists have described psychotogenic mothers, fathers, and general family settings, aside from specifics of individual development (Lidz et al. 1956). Sociologists have shown relationships to urban and rural populations and socioeconomic classes (Faris & Dunham 1939). Cultural anthropologists differ on whether more advanced cultures may have a greater incidence of psychoses than do primitive ones (Benedict 1958). Semanticists have related schizophrenia to the double bind and to semantic confusion. Geneticists have had a field day only occasionally interrupted by careful studies (Tienari 1963). Physical anthropology, by way of Kretschmer and Sheldon, has not lacked a voice, nor has such a factor as birth date (season of the year) been neglected (Barry & Barry 1964). In fact, hardly a week goes by without some etiological claim being mentioned in the popular or scientific press, and hardly a year without the total crop of claims being thoroughly discredited.

Just as the implication of the spirochetes in general paresis and the ensuing fever treatment raised the hope for similar etiology and therapy of psychoses, so the physical treatment modalities, by inference, were held a promising road for the uncovering of etiology. Sakel, Meduna, Cerletti and their followers were thus influenced, respectively, by insulin, metrazol, and electric shock treatment; they all formulated etiological theories which did not bear the burden of systematic investigation. The latest flurry of this type of research was produced by the advent of psychotropic drugs: if tranquilizers produce symptomatic changes in psychotics, and if these tranquilizers seem to have an effect, for example, on serotonin metabolism, then one might suggest that a serotonin disorder produces psychoses. By the same reasoning, if monoamine oxidase (MAO)-inhibiting drugs benefit depressions, it was felt that maybe MAO is etiologically implicated in the production of depression. Of course, it quickly turned out that different tranquilizers have their effect by different pathways and that drugs not affecting MAO also could lift depressions (for instance, amitriptyline). [SeeMental Disorders, article onBiological Aspects.]

Some of the most ambitious research was carried out by means of the so-called model psychoses and experimental analogues. Long ago, it was known that certain drugs, notably mescaline, bulbocap-nine, and others could produce psychoses not unlike schizophrenic psychoses. The most widely heralded drug in the 1960s was LSD (lysergic acid diethylamide-25). The most ambitious hope was to produce psychoses experimentally, then to be able to abolish them with a tranquilizer. As it happens, LSD-induced psychosis has only little resemblance to schizophrenia (except in borderline schizophrenics, in whom LSD, like many other traumata, can apparently induce a genuine psychosis, if one is not cautious enough to screen subjects). Other physiological experimental investigations only suffered from oversimplification and artifacts.

To confound the issue further, or, rather, to clarify the fact that psychosis is apparently a condition which is merely the final common path of many different effects on ego functions, interesting experiments in sensory deprivation or perceptual isolation (Lilly 1956) showed that psychosis-like conditions with hallucinations and delusions could be induced in some subjects put into these experimental conditions. [SeePerception, article onPerceptual Deprivation.]

The subject of research in psychosis can, therefore, be summarized by saying that hardly any of a worthwhile nature exists so far, with the exception of some rather careful work refuting a variety of heuristic claims (Kety 1959). Such claims have usually been the result of oversimplification, lack of controls, and lack of sophistication. It is my strong personal belief that progress will come only when an integrated, highly coordinated, multidis-ciplinary, extremely extensive and intensive approach is made, preferably under one roof, such as a “national institute for psychoses research.” Because of a lack of coordination and integration of research, the awarding of individual research grants has so far shown nothing but disappointment, from any basic standpoint.

Leopold Bellak

[Directly related are the entriesDepressive Disorders; Mental Disorders; Neurosis; Schizophrenia. Other relevant material may be found inMental Disorders, Treatment Of; Mental Health; Psychiatry; Psychoanalysis, especially the article onEgo Psychology; Psychosomatic Illness; and in the biographies ofFreud; Meyer; Sullivan.]

BIBLIOGRAPHY

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Wechsler, David (1939) 1958 The Measurement and Appraisal of Adult Intelligence. 4th ed. Baltimore: Williams & Wilkins. ? First published as The Measurement of Adult Intelligence.