Souza, Gustavo F. J., M.D.
Gustavo Fernando Julião de SouzaPsychiatric PhysicianStudent's Advisor at "Hospital das Clínicas" UFMG (Federal University of Minas Gerais)
Abstract - Diagnosing and treating atypical psychoses has always been a challenge to clinical psychiatry, hence the need of further phenomenological studies of these clinical pictures. The aim is to clinically unify and homogenise them in spite of their apparent psychopathological variety. In this paper, by using a clinical case to trigger a theoretical discussion, the author presents a detailed phenomenological analysis of atypical psychosis, establishing uniform phenomenological standards to make the diagnosis and treatment of these cases easier. In addition, he proposes the concepts of primary and secondary "morbus" and characterological "prism", in an attempt to clarify the psychopathological and clinical relations between personality disorders and atypical psychoses. Finally, the author suggests these cases should be referred to as "psychoid states" for the sake of its nosographic uniqueness.
Key Words: atypical psychosis, personality disorder, psychoid states, phenomenology
The main objective of this article is to contribute to the establishment of phenomenological borders for atypical pshycosis pictures and to clarify its relation with a particular symptomatology ¾ referred to as psychoid ¾ - manifested in some patients with personality disorder. These clinical pictures usually mislead psychiatrists, especially beginners, due to the great variety of psychopathological manifestations presented by patients, and are placed on the phenomenological border of what is traditionally classified either as "neurotic symptoms" or as "psychotic symptoms". I believe DSM(1,2) is actually a valuable tool for classifying mental disorders, making psychiatric diagnoses more accurate, specific and reliable. However, as far as psychoses are concerned, there is a wide range of psychopathological symptoms which is perhaps limited and simplistic, considering the great complexity and extreme clinical polymorphism of these intriguing anomalous experiences. In fact, some of the psychopathological terms used in DSM(1,2), such as "delusion", "hallucination","incoherence or marked loosening of associations", are regarded as insufficient and rather generic to describe more complex psychotic experiences characterized by any clinical polymorphism. In the cases of psychoses manifested in patients with personality disorders, the diagnostic criteria mentioned in DSM(2) are vague and inaccurate, leading to a tacit overlap of abnormal reaction caused by characterological dysfunctions with atypical psychotic symptoms and, as a result, raising doubts and controversy about the disagnosis. These qualifying systems leave little space for diagnoses of atypical psychoses, which are not phenomenologically sensitive (Brief Psychotic Disorder and Psychotic Disorder Not Otherwise Specified). HATOTANI(3), reviewing the development of the "atypical" psychosis concept in Europe and United States, showed several terms used for describing the group of psychoses that do not phenomenologically fit in the traditional Kraepelinian dichotomy. He lists "delusional Bouffée" (French School), "Cycloid Psychoses" (Leonhard, Perris), "Reactive Psychoses" (Scandinavian School) and "Acute Schizoaffective Psychoses" (Kasanin) as the terms commonly used to refer to those psychotic cases with acute beginning, polymorphic symptomatology and good prognosis. JAREMA(4) presents a clinical case of a 38-year-old woman who experienced two severe mixed episodes, with acute affective and paranoid symptomatology and good prognosis, and regarded it as "Cycloid Psychosis". RIVET et al(5), taking 113 cases out of about 1,000 consecutive hospitalizations, defined them as "paraschizophrenic states" and classified them, according to DSM-III-R criteria, as follows: borderline personality disorder (27 cases), schizoid (40 cases), schizotypal (15 cases), schizophreniform disorder and unspecified psychotic disorder (17 cases), and brief reactive psychosis (14 cases). YEUNG et al (6) researching, through scales, personality disorders and traits in first-degree relatives of psychotic patients concluded that those related to "atypical psychotics" could form a group apart. KENDLER et al(7), in an extensive study conducted in Ireland which included 1,544 first-degree relatives of five groups including schizophrenia, other nonaffective psychoses, psychotic and nonpsychotic affective illness, as well as unselected controls, concluded that schizotypy is a multidimensional and complex clinical construct whose dimensions differ enormously both in extent and in family's vulnerability to schizophrenia. Subpsychotic thought disorder, signs of negative schizotypy such as poor rapport, odd behaviour, deficient occupational functioning and social isolation or avoidance are more prominent in relatives of schizophrenics than in those relatives of controls. Another important study(8) recently made came to the conclusion that family's vulnerability to schizophrenia is not presented by families of probands with afftective disorder. However, schizoaffective disorder and the personality disorders of Group "A" could be found in families which have both schizophrenic and affective disorder probands. Furthermore, the presence of psychotic affetive disorders do not seem to imply vulnerability to schizophrenia. MAFFEI et al(9) analysed the hypothesis put forward by DSM-III-R that some personality disorders are connected with liability to Brief Reactive Psychosis, and found some consistency in the study. On the other hand, AKISKAL(10) has proposed that some borderline personality disorders seem to represent subaffective expressions of mood disorders, hence should be placed in the bipolar disorder spectrum. This author mentions the term "borderland" which, according to him, refers to a vast unstable temperamental area involving 4-6% of the population as a whole, against 1% of the classical bipolar disorder. He also defines three basic kinds of temperament ¾ dysthymic, irritable and cyclothymic ¾ and claims that the "stable instability" of these cases is secondary compared to the basic temperamental affective dysregulation that would have worsened in times of prominent emotional storms in difficult periods of these patients' biography. AKISKAL(11) has also developed and framed the concept of clinical "spectrum" of bipolar disorders, drawing special attention to the phenomenological aspects of mixed affective states and pointed out that many of the patients who clinically manifest ultrarapid cycling are morose, gloomy with a labile and irritable mood. These features can be easily mixed up with the patient's way of being and that is the reason they are misinterpreted and diagnosed as bordeline personality disorder and the patients are deprived of potential therapeutic benefits provided by mood-regulating agents. In another study recently done, AKISKAL et al(12) compared 143 patients who manisfested mixed states with 118 maniac patients, and then divided the former group into "dysphoric mixed mania" (54%), "agitated psychotic depression" with irritable mood and flight of ideas (17.5%) and "unproductive inhibited mania" with tiredness, indecision and lack of confidence (26%). They concluded that the phenomenology of mixed cases is not only a simple overlap of opposite affective symptoms, but in some cases can also represent either the intrusion of an excitable-outgoing phase into a depressive temperament or the outbreak of a melancholic episode in a hyperthymic temperament. Despite the wide variety of aims and methods of the research carried out, as we have seen, there seems to be an agreement on a question: the link between atypical psychotic cases and personality disorders is still unknown. After nearly two decades treating atypical and uncharacteristic psychotic cases, I am of the same thought. The word "atypical" conveys the meaning of something irregular that does not fit in any typical ou uniform standard. However, we have reason to believe that multiform clinical expressions of these cases can, at least in principle, be the result of a sequence of understandable pathological events. In other words, in spite of their apparent irregularity and clinical polymorphism, there may be an underlying order in the sequence of the physiopathological processes which would enable us to predict and outline those phenomenological manifestation clearly. Moreover, if that is possible, would it be reasonable to try to define, although it may seem rather paradoxal, a phenomenological standard for psychotic atypicality (14), which could make the diagnosis and treatment of these cases easier? In the next section I present a clinical case I have been following for some years which illustrates the theoretical discussion that follows.
I met M. in September 1992, when she was hospitalized in a psychiatric clinic due to one of her nervous breakdowns. I had been called by her husband, who is also a doctor, to assist her as the previous psychiatrist had quit the case. She was thirty six years old, slender, kind gestures and sparse quiet speech. She looked skinny and frail, showing a melancholic look in her haggard face. I was well aware of the serious conditions she was in, based on her husband's and her former psychiatrist's accounts. For some years, she had been going through crises which jeopardized her relationship with her husband and her care for her seven-year-old daughter. According to him, sharply and periodically, M. would show a sudden and radical change in her behaviour, turning from a tender, careful to a hostile, rude and irritable person, being suspicious, scared and bound to have outbursts of anger and tears without any apparent reason. She would also become entirely absent-minded and aloof regarding the household responsabilities and forget her daily appointments. M. was also restless and suffered from insomnia, always suspecting her husband would harm her in some way. When in disagreement with him, she assumed an incredibly unusual attitude like outbursts covered up by an empty and rude drama. Her husband could notice signs of incoherence and inappropriateness in his wife's behaviour, however, despite being a psychiatrist, he could not be sure it was a well-defined psychotic picture. It seems that those attitudes were closer to the classical psychotic incongruity than to the well-known belle indiférènce. He said that, at those moments of crisis, his wife would hardly ever stay at home, multiplying considerably her professional work to such an extent that her occupational behaviour acquired a maniform connotation. At home, she showed either moroseity or a preposterous and resentful verbosity, along with extreme emotional instability and sharp, incomprehensible changes in her mood. On some occasions, she had silly, childish whims and, on others, she would become mysteriously sneaky and counterfeit and, suddenly, accuse her husband of a meaningless fact that had happened many years before and had apparently been forgotten. She sometimes traveled unexpectedly with no money nor personal belongings, claiming to have business appointments and not worrying about leaving a message or an explanation about it. The house was always neglected and the little girl looked skinny and desserted. M. remained in hospital for about fifteen days and, during that time, we had several interviews that revealed few conclusive psychopathological data. The patient's speech as well as her accounts and answers to some questions seemed, at first, suitable and truthful as a whole, although some of her statements were not convincing at all. For instance, she claimed she had been working hard because her marriage was not going well and she was very ambitious to succeed in her career. Although the patient was surely trying to disguise her symptoms by using simple and unembellished explanations, it was clear she was not under an extensive delusion that could prevent her form being self-critical and irreversibly impair her cognition of reality, nor suffering from vivid hallucination or typical delusional perception. Nevertheless, as she started getting used to my hospital visists, she felt comfortable and described her anomalous experiences in details. After recovering, M. told me she felt that everything changed during her crises. People looked at her differently, some of them had a different expression on their faces which were covered with threatening and hostile colors. However, she was not able to identify any clear evil intentions, limiting herself to live in a real whirl of fear and mistrust that melted as quickly as it came up. Everything seemed distant and dark, loaded with oppresive and slightly magic atmosphere. At times, a sudden conviction came to her mind, like a flash, that her life was in danger and her husband could kill her. As a result, she was overcome by panic and ran out of the house desperately without any place to go. This kind of thought seems a sort of volatile and fleeting cognition imposed to consciousness due to its intensity rather than its coherence and firmness, and afterwards turning into a fragile and gleamy intuition. She lacked, however, a lasting, irrefutable personal conviction which characterizes the actual delusional cognition, having occasional cognitive flashes that struck in the patient's stormy subjective sky from time to time. On another occasion, she was in a bank when she had a strong impression, though briefly, that some of the notices to the account holders on the walls were actually addressed to her and they had been fixed there as "signs" to warn her of something ineffable and incomprehensible. She left the bank hurriedly and when she reached the street, still dazed, realized she might have misunderstood it, and that the impression could be the result of all the ongoing tension and nervousness she had been going through on those days. However, after that she could not help thinking about it uninterruptedly, considering and reconsidering the likelihood of her experience. In this example, it can be seen that the anomalous experience decribed lacks a specific delusional meaning which is always linked to complete perception and has a "revealing" feature when refering to actual delusional perceptions(13). In addition, her personal belief in it proved to be rather floating, vanishing after some time. According to the patient's family, she has always been introverted, sensitive, mild tempered and when she was younger, was a rather shy, fearful and impressionable, likely to faint when facing situations that stirred up strong emtions. In her early adulthood, she was solitary, thoughtful and idealist, keen on Utopian and eccentric ideologies to which she would devote herself fanatically. Her father as well as her paternal grandfather had been reported to suffer from Bipolar Disorder and her sister from Nervous Anorexia. The complementary examinations required (blood test, including thyroidogram and enchefalo- tomography) were normal. She had already made several attempts to undergo analytical-based psychotherapic treatment, which had not brought out any of her symptoms. The improvement on her chronic symptoms and the temporary control of her crises were achieved only after taking a series of ECT prescribed by her doctor a year before.
Course and Management
M. recovered remarkably after taking lithium carbonate (900 mg/day) along with haloperidol (7 mg/day, later reduced to 2mg/day) during her staying in hospital and also afterwards, during out-patient treatment. Later occasional depressive changes were solved at first with amitryptyline, and then with fluoxetine. About three years ago, coinciding with the worsening of her marriage, she started showing eating disorder (bulimia) and impulsive money spending (tendency to externalise through excessive shopping) alternately, besides suffering outlines of two crises characterized by mild paranoid and self-referential experiences. The latter were easily treated by increasing the haloperidol dose slightly, whereas the former were treated associated with clormipramine (50 mg/day). The patient, at any moment, had to stop working and is now starting a masters degree; despite looking sad with the imminent possibility of a marriage breakup.
Firstly, M.'s clinical history shows that her disease had, to a certain extent, spared her, as her social and professional performances were suitably normal in the periods between crises. However, since the first contact, the inexpressiveness in her facial and gestural mime as well as the vague mechanical connotation in her expression of the uninterrupted flow of daily affectivity could be easily noticed. Her affetive modulation and resonance were surely reduced, along with a constant lack of confidence that underlay her hesitant speech and fleeting intimate contact. In her every-day life, M. seemed dysthymic, passive and hypoabulic, and at times, looked cold and distant. She had a restricted social life, limiting herself to be in contact with her parents, brothers and sisters, and at work, used to devote herself entirely to tasks which aroused her interest. On the other hand, she was extremely vulnerable and liable to rejection and desertion, and most of her crises were apparently triggered by conjugal conflicts. In those moments, she was overwhelmed by desperation and anxiety, and sometimes would present a symptomatology that suggested a pre-crisis, becoming impulsive, unstable and irritable.
After having analysed M.'s temperamental records and taken all her five-year clinical history into account, I can state that she did not suffer from a complete personality disorder, but had significant features of borderline and schizotypal personality disorder(1,2). M.'s acute crises were phasic and could be controlled by lithium carbonate, a powerful mood-regulating agent. She manifested affective symptoms typical of manic and/or hypomanic phases, such as crises of rage, hyperkinesia, outbursts and restlessness. In addition, there was also a clear familial liability to bipolar disorder and an excellent response to ECT. However, a careful analysis of the phenomenological core of the patient's anomalous experiences revealed some diffusely schizomorph(14) material. Delusions of grandeur, omnipotence and self-sufficiency supposed to be met in typical states of elation were not found at any moment. On the contrary, we found a whril of suspiciousness, mistrust and perplexity when facing something that seemed a complete, ineffable transformation of the world which came out loaded of deep, self-referential cognition. At first, these experiences seemed short, fleeting waves which surrounded her consciousness for a short period of time and faded afterwards. It seems that they originally corresponded to delusional perceptions (wahnwahrnehmung) and delusional experiences (wahneinfall) in the sense defined by KURT SCHNEIDER(13), but did not configure themselves entirely, being abortively and unsuccessfully shaped.
Having "dissected" this case phenomenologically, we can now try to establish a credible theoretical-conceptual model to explain the atypical psychotic symptomatology in general terms. Let us go back to the clinical case and use it as a trigger for a theoretical discussion. In my opinion, M. suffered from a bipolar mood disorder which manifested periodically, particularly after her exposing to psychosocial stress (conjugal). Moreover, we can question the extent to which the borderline personality traits corresponded to subaffective fluctuations(10) of unstable mood, manifesting as impulsivity and ill-timed, exaggerated emotional reactions at the slightest threat of a marriage break up. On the other hand, as already mentioned, her personality showed some schizotypal features, such as restricted and unexpressive affectivity, contemplative temperament, special interest in eccentric ideologies to which she would devote herself fanatically, floating social anxiety tending to isolation and poor rapport(7). Considering that schizotypy should be seen as a complex and variable multidimensional clinical construct(7), we can conclude that, in the case under discussion, her personality was not markedly affected to the extent that it would cause visibly incapacitant social or occupational harm. However, those schizotypal traits and features of M.'s personality could give an amplified schizomorph(14) look to definition of her clinical picture as an atypical case and that would be the phenomenological-dynamic(15) core of the theoretical model for these atypical psychoses. In the case mentioned, when the mixed and(or) bipolar affective disorder ¾ the actual primary "morbus" ¾ affects the schizotypal characterological "prism" or "filter", it launches a sequence of secondary physiopathological changes ¾ the secondary "morbus" ¾ and produces the final clinical morphology, that is, affective symptoms mixed up with frustated schizophreniform symptoms. My broad clinical experience in dealing with these pictures, makes me think that their clinical symptomatology could come from the incomplete and unsuccessful genetic outbreak of the two nosological entities supporting the Kraepelian nosography, that is, the "dementia praecox" group and the "manic-depressive insanity" group(16). Recent clinical and genetic research on schizotypy(7,17,18) leads to the belief that this kind of disorder attains a vast spectrum of shapes or clinical states which could be referred to as "subprocessual", considering the term "process" strictly in the Jasperian sense(19,20). Thus, there would be the subaffective clinical states(10,21) on one side and "subprocessual" clinical states on the other. At the strike of the primary "morbus" balance (by activating a bipolar disorder, for example) in the first physiopathological dimension, it would launch a vast physiopathological activation in the second dimension (schizotypal characterological dysfunction), giving rise to entwined clinical symptoms. If the "subprocessual" schizotypal condition had as much genetic potential as the affective or "subaffective" one, the final clinical manifestations resulting from the simultaneous balance strike would probably be of the classical schizoaffective kind(1,2). In other words, with a more or less fair distribution of the psychopathological symptoms typical of the two nosological conditions and unfavourable clinical history. In this theoretical-conceptual model, the reader should try to visualize the extreme dynamism and continuous movement happening at every moment and underlying the physiopathological changes along with the phenomenological ones. That is the only way we can put aside the static and stationary nosological view which has always clouded and limited our clinical sense, diverting us from the variety and multiple possibities of viewing something psychopathologically new. As for atypical psychoses, whose symptomatology has just been analysed, the clinical course is usually favourable and benign and the acute crises are fleeting and brief. They can be regarded as psychoid clinical states as they are characterized by a unsuccessful and frustated psychopathological miscellany (the suffix "oid" conveys the meaning of "aspect or shape", "similar to" and "related to").
Having finished the theoretical discussion of our clinical case, we are now able to establish a phenomenological standard for atypical psychoses(14), which relies on the following criteria: 1- Atypical psychotic patients usually have either significant traits or complete personality disorders in a pre-morbid phase, with emphasis on borderline and schizotypal personality disorder. 2- Phenomenologically, the anomalous experience predominant in atypical psychotic cases consists of frustated, unsuccessful, abortive symptoms of psychopathological manifestations common in typical and well-defined psychoses which come from two basic endogenous orientations, schizomorph or affective. 3- Atypical psychotic cases comprised of anomalous experience with intense and dynamic temporal symptomatological migration, similar to a real "pan-neurotic" polymorphism, should be nosologically regarded as belonging to the affective illness circle. In my opinion, the criteria pointed out above can help clinical psychiatrists to determine a more reliable psychiatric diagnosis and a more effective treatment for those atypical cases. My proposal is that these cases should be referred to as psychoid disorders or states(14), considering their nature and features according to what has been discussed so far. My claim is that these pictures result from some bipolar affective disorder activity (primary "morbus") that intermediating the existing anomalous characterological "filter"or "prism" (secondary "morbus") would give rise to the final clinical-phenomenological look. Therefore, these clinical entities would belong to the "lithium psychoses" spectrum(14) as they are cases which respond primarily to mood-regulating agents. Far from willing to disturb the psychiatric nomenclature by adding an unnecessary psychopathological term, I hope this new term can unify and homogenise the extensive nosological area which is still unknown and unexploited. Anyhow, it seems useful to take any initiative with the aim of clarifying psychotic phenomena, especially those more complex, intricate clinical pictures which represent a real challenge for diagnoses and therapy in clinical psychiatry.
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