the predelusional state: a conceptual history

9
The Predelusional State: A Conceptual History F. Fuentenebro and G.E. Berrios The predelusional state (PDS) is defined as the set of psychopathologic events preceding the crystallization of delusions, and includes strange cognitions, moods, conations, and motor acts that may be fleeting and defy description. This review exclusively deals with the historic aspects of PDS. It is noted that during PDS the patient is expected to report experiences for which, on account of their novelty, he may not even have a name. Thus, it is quite likely that according to culture and personal codes and to the conceptual brief of the interviewer, similar experiences might be re- ported as depersonalization, bodily sensations, dys- phoria, changes in perception of reality or time, disso- lution of "ego boundaries," etc. It is therefore not surprising that since the 19th century, PDS has been considered a disorder of cognition, emotions, volition, and consciousness. Copyright © 1995 by W.B. Saunders Company D URING THE 17th century, Hobbes and Locke rendered delusions a hallmark of insanitya; by the 1830s, forms of insanity without delusions began to be reported, but this did not affect their predominant position.2 During the same period, delusions were defined as "wrong beliefs," and this model has endured. 3 By the 1850s, particularly in the studies reported by Baillarger and Falret, ~ interest developed as to the form of delusions; by the 1890s, this had focused on content, and based on such analysis many subtypes of psychoses were described. 4 The psychodynamic movement also emphasized content, but the rules on which its hermeneutic algorithm depends have not yet been fully specified. Of late, there has been renewed interest in the origin,5 structure, 6 and neurobiol- ogy of delusions.7a° In clinical practice, delusions are often the culmination of earlier clinical events. As De C16rambault H wrote, "by the time the delusion appears the psychosis is usually of long-stand- ing. Delusion is a construct (superstructure)" (p. 466). The experiential events immediately pre- ceding crystallization of the delusion will be called the predelusional state (PDS) in this review, and include cognitions, moods, cona- tions, and motor acts (and combinations thereof). Although classic authors mention PDS, only few have explored it in detail. However, it is unclear whether PDS is a necessary stage in delusion formation. Should this be the case, as the pioneering study reported by Chapman a2 suggested nearly 30 years ago, PDS might be- come an important source of information on the neurobiology of delusions. Fleetingness and opacity make PDS difficult to research. By the time the patient is brought to hospital, PDS has often disappeared either due to early medication or to the evolution of the disease itself. This is why classic studies on PDS 12,13are mostly based on retrospective data. The fact that PDS has been excluded from current glossaries (e.g., DSM-IV) does not help, and it has been consequently ignored by some important researchers. 14 Others even confuse PDS with "primary delusion. ''15 Because the evolution of PDS has not yet been mapped out in detail, this review will exclusively deal with its history up to the 1950s. (For its most recent history and clinical and theoretic aspects, see Berrios and Fuentenebro. 16) THE MAIN PSYCHIATRIC SCHOOLS The German School Wilhelm Griesinger t7 was one of the first to describe PDS in detail: Observation shows that most mental disorders are first manifested, not by senseless talk or extravagant acts, but by morbid changes of mood and anomalies of the self. The earliest stages of insanity consist of an aimless feeling of ill humour (objectlosen Gefiihle der Unauf- gelegtheit), discomfort, oppression, and anxiety, result- ing from the fact that the new ideas and instincts caused by the cerebral affection are at first obscure... the new morbid perceptions and instincts produce splitting of the mind, a feeling of dissociation of the personality (Losseins der PersOnlichkeit) and of over- whelming of the self (Ueberwdltigung des lch) (pp. 63-64). And a few years later, when referring to From the Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; and the Department of Psychiatry, Universityof Cambridge, Cambridge, UK. Address reprint requests to G.E. Berrios, M.D., Department of Psychiatry, Universityof Cambridge, Addenbrooke's Hospi- tal (Box 189), Hills Road, Cambridge, UK. Copyright © 1995 by W.B. Saunders Company 0010-440X/95/3604-0007503. 00/0 ComprehensivePsychiatry, Vol. 36, No. 4 (July/August), 1995: pp 251-259 251

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Page 1: The predelusional state: A conceptual history

The Predelusional State: A Conceptual History

F. Fuentenebro and G.E. Berrios

The predelusional state (PDS) is defined as the set of psychopathologic events preceding the crystallization of delusions, and includes strange cognitions, moods, conations, and motor acts that may be fleeting and defy description. This review exclusively deals with the historic aspects of PDS. It is noted that during PDS the patient is expected to report experiences for which, on account of their novelty, he may not even have a name. Thus, it is quite likely that according to

culture and personal codes and to the conceptual brief of the interviewer, similar experiences might be re- ported as depersonalization, bodily sensations, dys- phoria, changes in perception of reality or time, disso- lution of "ego boundaries," etc. It is therefore not surprising that since the 19th century, PDS has been considered a disorder of cognition, emotions, volition, and consciousness. Copyright © 1995 by W.B. Saunders Company

D URING THE 17th century, Hobbes and Locke rendered delusions a hallmark of

insanitya; by the 1830s, forms of insanity without delusions began to be reported, but this did not affect their predominant position. 2 During the same period, delusions were defined as "wrong beliefs," and this model has endured. 3 By the 1850s, particularly in the studies reported by Baillarger and Falret, ~ interest developed as to the form of delusions; by the 1890s, this had focused on content, and based on such analysis many subtypes of psychoses were described. 4 The psychodynamic movement also emphasized content, but the rules on which its hermeneutic algorithm depends have not yet been fully specified. Of late, there has been renewed interest in the origin, 5 structure, 6 and neurobiol- ogy of delusions. 7a°

In clinical practice, delusions are often the culmination of earlier clinical events. As De C16rambault H wrote, "by the time the delusion appears the psychosis is usually of long-stand- ing. Delusion is a construct (superstructure)" (p. 466). The experiential events immediately pre- ceding crystallization of the delusion will be called the predelusional state (PDS) in this review, and include cognitions, moods, cona- tions, and motor acts (and combinations thereof). Although classic authors mention PDS, only few have explored it in detail. However, it is unclear whether PDS is a necessary stage in delusion formation. Should this be the case, as the pioneering study reported by Chapman a2 suggested nearly 30 years ago, PDS might be- come an important source of information on the neurobiology of delusions.

Fleetingness and opacity make PDS difficult to research. By the time the patient is brought to hospital, PDS has often disappeared either due to early medication or to the evolution of

the disease itself. This is why classic studies on PDS 12,13 are mostly based on retrospective data. The fact that PDS has been excluded from current glossaries (e.g., DSM-IV) does not help, and it has been consequently ignored by some important researchers. 14 Others even confuse PDS with "primary delusion. ''15 Because the evolution of PDS has not yet been mapped out in detail, this review will exclusively deal with its history up to the 1950s. (For its most recent history and clinical and theoretic aspects, see Berrios and Fuentenebro. 16)

THE MAIN PSYCHIATRIC SCHOOLS

The German School

Wilhelm Griesinger t7 was one of the first to describe PDS in detail:

Observation shows that most mental disorders are first manifested, not by senseless talk or extravagant acts, but by morbid changes of mood and anomalies of the self. The earliest stages of insanity consist of an aimless feeling of ill humour (objectlosen Gefiihle der Unauf- gelegtheit), discomfort, oppression, and anxiety, result- ing from the fact that the new ideas and instincts caused by the cerebral affection are at first obscure . . . the new morbid perceptions and instincts produce splitting of the mind, a feeling of dissociation of the personality (Losseins der PersOnlichkeit) and of over- whelming of the self (Ueberwdltigung des lch) (pp. 63-64).

And a few years later, when referring to

From the Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; and the Department of Psychiatry, University of Cambridge, Cambridge, UK.

Address reprint requests to G.E. Berrios, M.D., Department of Psychiatry, University of Cambridge, Addenbrooke's Hospi- tal (Box 189), Hills Road, Cambridge, UK.

Copyright © 1995 by W.B. Saunders Company 0010-440X/95/3604-0007503. 00/0

Comprehensive Psychiatry, Vol. 36, No. 4 (July/August), 1995: pp 251-259 251

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252 FUENTENEBRO AND BERRIOS

"delusional mood" (Wahnstimmung), Hagen 18 wrote:

"the disturbed affect may not be recognised, not only because patients are able to control themselves or because doctors do not always investigate this possibil- ity closely enough, but also---as a third r eason- - because the severity of the delusion itself may tend to mask or distract from the disturbed affect."

The view that delusions are a "hallmark" of insanity was challenged by Krafft-Ebing19: "the view of the lay person that delusions are a hallmark of insanity is erroneous." He defined delusions as disorders of the content of ideas (inhaltliche St6rungen irn Vorstellen) and pro- posed that thought disorder and loss of intellec- tual power (formale Stfrungen des Vorstellung- ~processes oder Ausfallserscheinungen der intellektuellen Seite des Seelenlebens) were more important to the diagnosis of the psychoses (p. 72). Delusions and hallucinations were closely related: "delusions arise as a result of either false judgements (ideatorischer Weg) or wrong perceptions (hallucinatorischer Weg)" (p. 74). Intellectual or sensory delusions may have con- scious or "organic unconscious" origin. There were three origins for delusions: (1) false judg- ments concerning abnormal states of conscious- ness or perceptions, (2) false combinations of percepts and experiences leading to defective conclusions, and (3) confusion of dreams or memories with actual events (Gediichtnissdelir- ien). The content of the delusions depended on (1) primordial, archetypal processes, (2) the predominant mood, (3) degree of education, and (4) changes in "extra-cerebral" organs (pp. 74-75).

Like Hagen, Bleuler 2° also emphasized the "affective" nature of PDS. Abnormal affect disrupted the processing of information and linearity of logical thinking, thereby facilitating the formation of delusions. Bleuler attributed a special role to "cathathymic" forces and sug- gested that the "transforming" power of affect severed many associations (pp. 178-179). For Lange, 21 a special affect and perplexity were the basic components of "delusional mood" (Wahnstimmung): "it is unclear what the rela- tionship is between delusional mood and delu- sions. It may well be that both events result from a third anomaly and hence no cause-effect rela-

tionship can be established between the two" (p. 280; our italics).

With regard to Wahnstimmung, Jaspers 22 wrote:

If we try to get some closer understanding of these primary experiences of delusion, we soon find we cannot really appreciate these quite alien modes of experience. They remain largely incomprehensible, unreal and beyond our understanding. Yet some at- tempts have been made. We find that there arise in the patient certain primary sensations, vital feelings, moods, awareness: 'Something is going on; do tell me what on earth is going on,' as one patient said to her hus- band . . . . A living-room which formerly was felt as neutral or friendly now becomes dominated by some indefinable a t m o s p h e r e . . , the use of the word 'atmo- sphere' might suggest psychasthenic moods and feel- ings perhaps and be a source of confusion; but with this delusional atmosphere we always find an 'objective something' there, even though quite vague, a some- thing which lays the seed of objective validity and meaning (p. 98).

Wetze123 explored the ineffability and affec- tive nature of delusional mood, which he called the "end of the world" experience. This he considered a special affective state, a "sinister foreboding." Mauz, 24 on the other hand, be- lieved that PDS was a disorder of consciousness and was accompanied by a feeling of "increased awareness and lucidity." This author believed that this was due to an accompanying feeling of "transformation of the self" or "psychological annihilation" (p. 34). Mauz believed that this "awareness of subjective change" (i.e., Berze's Bewusstheit der Veriindertseins ) was the hallmark of the schizophrenic process, for it was the "apperception of a threat to the self, or a weakening of individuality or an experience of insufficiency or a loss of capacity to act" (p. 34). Such experiences generated feelings of restless- ness, uncertainty, fear, confusion, and perplex- ity. Mauz goes as far as saying that the quality of the awareness may have a prognostic value, namely the more "lucid" the subject is with regard to his state, the worse the prognosis will be.

Gustav St6rring 25 defined PDS as a stage of perplexity as "the painful awareness of an inability to master external or internal situa- tions, this awareness is 'lived' by the subject as something inexplicable that deeply affects the self" (p. 90). This state of perplexity (Ratlo-

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HISTORY OF PREDELUSlONAL STATE 253

sigkeit) will disappear when the subject happens upon a delusion that "explains" his feelings. A core of "primary" anxiety, generated by the disease itself and related to a thalamic dysfunc- tion, is always found at the center of the perplexity state. St6rring also studied the pos- tures and motor disorder characteristic of per- plexity. The gesturing and wide-eyed facies of the perplexed patient he compares with the Darwinian description of states of surprise and stupefaction. The state of perplexity is common in schizophrenia and appears in response to the primary feelings of strangeness or acute anxiety engendered by this condition.

Like Lange, Kurt Schneider 26 also explored the link between delusional mood and delusion:

We stated that delusional perception does not derive from any particular emotional state, but this does not contradict the fact that delusional perception is often preceded by a delusional atmosphere brought on by the morbid process itself, an experience of oddness or sometimes, though more rarely, of exaltation, and often in these vague delusional moods, perceptions gain this sense of something 'significant' yet not defined. The delusional atmosphere is, however, very vague and can offer no content pointing to the delusional perception that ensues later, nor can we understand the specific content of the delusional perception in terms of it. The most we can say is that these perceptions are character- istically embedded in this atmosphere but are not derived from it. There is no need for the delusional atmosphere to jibe exactly with the emotional tone of the following delusional perception. The atmosphere may be alien and uncomfortable, the delusional percep- tion may be pleasant and cheering. Sometimes, how- ever, the abnormal interpretation of a perception does seem to spring more understandably from the motive- less, perhaps anxiety-ridden atmosphere. We would then take this as one of the common paranoid reactions of a psychotic, the morbid process being the prerequi- site. In practice, delusional perception and paranoid reaction may sometimes be difficult to distinguish. This provides occasion for leaving the diagnosis open for schizophrenia or cyclothymia. We have given the term preparatory field to this delusional atmosphere that sometimes precedes delusional perception (p. 109; our italics).

For Klaus Conrad 27 the development of schizophrenia included (roughly) five stages: trema (prepsychotic state), apophany and an- astrophO (development of delusions), apocalyp- tic (presence of catatonia and other syndromes), consolidation, and residual or defect state. PDS is included in the trema stage, which Conrad

considers predominantly affective in nature: indeed, "The number of cases of schizophrenia starting with endogenous affective symptoms (endogener Verstimmung) is high . . . trema can take the character of an endogenous depres- sion" (p. 39). Conrad notes that it is never observed that the latter can start with schizo- phrenic symptoms.

The French School

Important observations on PDS were made in 1845 by Moreau de Tours 29 who, based on his experiments with hashish, proposed that delu- sions originated out of a fait primordial. This concept, not dissimilar to Jackson's concept of dissolution, 28 was a "general law of nature" and dictated the way in which the "self ' underwent disintegration during disease. To Moreau, all forms of insanity resulted from the same set of causes (p. 44) and were similar to dreaming (p. 247). The fait primordial included "intellectual excitement, sudden or gradual dissociation of ideas, weakening of the co-ordination between the intellectual powers" (p. 226). All these psychologic causes have in common a "molecu- lar" mechanism: "there is weakening of the power to direct our thoughts at will, insidiously strange ideas take over in regards to a particular object of attention. These ideas, which the will has not called upon, have an unknown origin and become progressively more vivid. Soon they lead to bizarre associations . . . " (p. 63). These cause "a state of vagueness, uncertainty, oscilla- tion and confusion of ideas that often leads to incoherence. It is a veritable disintegration, a dissolution of the intellectual system" (p. 47). In the notion of fait primordial, Moreau was able to combine brain mechanisms and the psychologic hypotheses of the 1840s (pp. 40-47). 3o

Ball and Ritti 3j explored the pathogenesis of "sudden" delusional formation and suggested that these phenomena resulted from a "sponta- neous internal irritation" of the vegetative sys- tem (pp. 343, 414). At the time, a "seizural" model for symptom formation had become popu- lar in the wake of Tamburini's studies. 3z An- other original contributor to the debate was Jules Cotard, 33 who believed that states of emotional or motor overactivity were propitious to the development of delusions. For example,

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254 FUENTENEBRO AND BERRIOS

grandiose delusions in mania developed pari passu with the increase in activity in the motor or conative centers (centres moteurs ou voli- tionels). According to Cotard, "Hallucinations do not seem to contribute at all to the develop- ment of this kind of delusion" (pp. 367-368).

Jules S6glas 34 separated delusional ideas that were simple and transient (iddes d~lirantes simples et passag~res) from ddlires proper. The former were "secondary to interpretations of other symptoms such as hallucinations, emotions, in- tellectual events, perceptions and memories" (p. 224). S6glas based his ideas on Meynert's view that delusions preexist in all normal brains. However, mental illness causes a break of nor- mal associations and does away with the inhibi- tions of normal mental life. This releases abnor- mal images and facilitates the release of delusions (p. 226). According to this view, PDS is an inchoate cognition containing a sort of question that the patient eventually responds to by creating the delusion. What matters here is the cognitive act of perceiving the world or self as strange. This process culminates in a declara- tive statement. A good illustration for this view is found in a report by Magnan and S6rieux 35 on "chronic delusional states," in which four stages are recognized: incubation or "inner restless- ness," persecution, grandiosity, and "demen- tia." The incubation period may go unnoticed or be characterized by sadness, somberness, anxiety, and an acceptance by the subject of gradual increasing misinterpretations. Even less specific clinical features such as anorexia, insom- nia, and hypochondria may occur. This state of overalertness may in due course lead to ideas of reference and eventually to crystallized delu- sions. These, in turn, will become systematized when "confirmatory" experiences such as hallu- cinations enter the picture.

The contribution of Charles Blonde136 to PDS is crucial. Arguably the most original (and less well known to English-speaking psychiatrists) of French writers in his time, Blondel published in 1914 a classic book entitled La Conscience Morbide. He developed an explanatory model for the origin of delusions based on the view that PDS was conterminous with the personal- ized cluster of proprioceptive sensations known in his time as c~nesth~sie viscerale. This notion

was central to French psychiatry at the begin- ning of the 20th century and proved the experi- ential core of human consciousness. 37,38 In the "normal state," human beings partake in a collective form of consciousness (conscience so- cialisOe, including a public language inadequate for the description of their subjective events) and hence suppress their own c~nesth~sie. The onset of mental disorder is marked by an in- crease in cenOsth~sie that catches the attention of the individual, who soon realizes that his experiences have no equivalent in the collective consciousness. The ensuing affective restless- ness or conscience morbide (or PDS) is handled by the patient in either of two ways. He may continue experiencing it as a mysterious anxiety and restlessness or may attempt a description. To do the latter, he borrows from "normal discourse," and delusions are formed with a content of "recognizable" material (which leads the observer to try and understand it). However, the referential function of such content is manqu~ in that it has no real referent. La conscience morbide refers to a PDS, and its analysis is informative of the patient's actual experiences (and their origin).

The writings of Angelo Hesnard 39 span the first half of 20th-century French psychiatry. A keen exponent of psychoanalysis, his studies during the 1920s were marked by an imaginative eclecticism that included a model for the forma- tion of the psychoses. According to Hesnard, these evolved in four stages: loss of physiopatho- logic balance (humoral, etc.), endogenous and disorganized overproduction of affective experi- ences, formulation of justificatory cognitions (e.g., delusions), and full clinical expression. Each stage gave rise to its own symptoms. PDS corresponded to stages 1 and 2, during which obscure and ineffable bodily changes were expe- rienced by the subject (pp. 157-164).

De C16rambault 11 is another important early 20th-century psychopathologist. "Psychological automatism," central to his concept of psycho- ses, included organic and cognitive changes and corresponds to PDS. Psychological automatism is clinically expressed in disorganized conduct, thought disorder, etc., and later on in hallucina- tions (pp. 484-485). Hence, delusions were secondary, interpretative phenomena. De C16r-

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HISTORY OF PREDELUSlONAL STATE 255

ambault also highlighted the role of coenesthopa- thie, 38 internal sensations that provided the magma out of which hallucinations and delu- sions emerged. He spoke of "sensitive automa- tism," i.e., of the irruption into consciousness of primitive, ineffable, sensations that caused per- plexity and increased the likelihood of delu- sional formation (p. 435). 11 At the time, great writers like Mourgue 4° and Morsier 41 also took seriously the possibility that hallucinations may originate in the "vegetative" system.

Inspired by the writings of De C16rambault, Targowla and Dublineau 42 published in 1931 an important book entitled L'Intuition D~lirante. According to them, delusions were generated by the combined action of organic factors and the mechanism of intuition, and both were related to psychological automatism (pp. 300-303). Tar- gowla and Dublineau considered delusional content less important, for it tended to be stereotyped and similar in individuals of varying education and social class. What mattered was the form of the delusion. Delusional conviction, a dimension as primary as anxiety, was also important (pp. 255-273).

Before embarking on his psychoanalytic ca- reer, Jacques Lacan 43 published a substantial study on paranoid states in which he dealt with the formation of delusions. Inspired by Jas- pers, 22 he sought to identify a "process"--both neurobiological and psychological--that facili- tated crystallization of the psychosis. He sug- gested the existence of a "morbid factor X" (p. 207) that caused the development of both delu- sions and hallucinations. Lacan also recognized three stages in the evolution of the psychotic process: acute, affective, and consolidation (p. 209). The first two are conterminous with PDS.

Based on the hierarchic model of Hughlings Jackson and classic French psychopathology, Henri Ey 44 proposed that all mental disorders resulted from changes either in the longitudinal (diachronic) or cross-sectional (synchronic) structure of consciousness. PDS, according to Ey, varied in frequency and duration and was characterized by manifestations resulting from physical changes caused by the psychoses such as nervousness, insomnia, hypnagogic experi- ences, irritability, mood disorder, lack of psycho- logic stability, restlessness, agitation, anorexia,

amenorrhea, vasomotor and digestive disorders, and even soft neurologic signs. These symptoms occurred in the context of a disorder of con- sciousness that he described as "a reorganisa- tion of the boundaries of reality." It was in this fertile ground that delusions crystallized.

The delusional state proper was character- ized by (1) passivity, i.e., the subject's conscious- ness comes under the control of the delusion, (2)pur vecu, i.e., the private experience of alone inhabiting a delusional state, and (3) the fact that delusions are just one aspect of the deeper process of "going mad" (just like dreams relate to sleeping) (p. 36). 21 The acute delusional state always emerges in the context of a disorder of consciousness, but whether it becomes system- atized and chronic depends on whether it be- comes linked to personality and the being of the subject. In this way, delusional states become traits.

The Spanish School

By far the most important writer in this area is Llopis, 45 who applied to delusional mood his own theory of the destructuring of conscious- ness, which he had developed in his study on pellagra psychosis. 46 Llopis proposed that the psychoses often caused somatic sensations that were experienced by patients as anxiety or euphoria. These affective changes are therefore primary sensations perceived ab initio as "as if" experiences. However, the psychoses also bring about a fundamental change in the content, level, and structure of consciousness, and there- fore, sooner or later, patients lose control over the cognitive organization of their world and no longer can hang on to the "as if" qualification. The net result is that they begin to perceive their somatic sensations as caused by an exter- nal agency. In this sense, the affective sensa- tions are for Llopis the basis for PDS and delusions proper (pp. 23-26). 4v

Llopis proposed an interesting distinction between what he called "active" (delusi6n viva) and "inert" (delusi6n inerte) delusions. The former was kept alive by emotions (delusional mood), and the latter was but the "corpse," or "mnemic footprint" of a delusion. Due to their "associationistic" nature, inert delusions might occasionally be kindled by an emotional up-

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256 FUENTENEBRO AND BERRIOS

heaval. Showing great penetration, Llopis also called into question the time-honored distinc- tion between primary and secondary delusion, which he saw as the ends of a continuum. For him, all delusions were incomprehensible in that they emerged from somatic changes; their content was unimportant.

Marco-Merenciano 48 also proposed that the "delusional mood in schizophrenia exhibits all the features of an ineffable 'aura' that tends to last a great deal . . . it can pass on or change itself into a sort of twilight s t a t e . . , or merge into the disease itself" (p. 80). These views are forerunners of current views on the association between epilepsy and schizophrenia. Lafora 49 also supported the view that this sensation of transformation may be an important source for the "primary symptoms" of schizophrenia (p. 10).

To the Galician psychiatrist Cabaleiro Goas, an important element in the development of PDS also was a disturbance of awareness. He agreed with the view that affective experiences might, on occasion, predominate, but they were always "associated with hypotonia 5° of conscious- ness" (p. 972). 21 However, the central issue was that "an alteration of consciousness is required for the development of delusions" (p. 9 7 4 ) . . . "we believe that in delusional mood there is something more than a disorder of affect, namely, a hypotonia of consciousness" (p. 987), and "delusional mood reflects more a profound disorder of consciousness than the perception of something uncertain" (p. 1007). 51

English-Speaking Psychiatry

John MacCurdy was a Canadian who after 1926 taught in Cambridge: 2 Before coming over to the United Kingdom, he had worked with Augustus Hoch and John Kirby and helped edit Hoch's book on stupor: 3 Following Kirby, Mac- Curdy 54 described perplexity as a two-stage process: subjective stupefaction was followed by overretardation and perplexity. He believed that perplexity was the source for the formation of delusions:

Most often from this general matrix there emerges one dominating type of delusion and from the reaction ceases to be perplexity and becomes depression, anxi- ety or involutional melancholia, stupor or mania. Per-

plexity in the sense of a consistent psychosis tends, therefore, to be a brief reaction--a few weeks or months; it is often merely a brief interlude or transitory state and is commonest of all during the onset of manic-depressive attacks. Relatives describe the per- plexity syndrome with great frequency when they tell how the psychosis began (p. 422).

With regard to the specific role of perplexity in the formation of delusions, MacCurdy 54 stated: "naturally, before the sense of reality is wholly lost, a patient may suffer from this kind of thinking (trying to reconcile the irreconcil- able) and be puzzled until such time as the effort to be logical is relaxed. Hence, we may find--and often do---the symptoms of perplex- ity appearing in the earlier stages of dementia praecox" (p. 422). Thus, for MacCurdy, as for St6rring, perplexity is an important marker of early schizophrenia.

In 1931, Jelliffe 55 made the interesting sugges- tion that the particular motor changes (as seen in schizophrenia, encephalitis, and Parkinson's disease) might contribute to the way in which Gestalten of the world develop in these patients. Lastly, and inspired by the writings of Schilder, 56 Chapman 57 remarked on the important role played by motility and imagery in delusion formation: "on reception into consciousness of a memory image of another person their motil- ity is automatically affected in a way which accommodates to that particular image content and lasts for the same duration of time as the presentation of the image in consciousness" (p. 773). As for clinical phenomena such as "block- ing" (entailing inter alia a feeling of change in movement), he wrote, "observable features at this stage were complete bodily inmobility, speech arrest, visual fixation, and apparently complete inattention" (p. 777). 27

THE 1950 FIRST WORLD CONGRESS OF PSYCHIATRY

Since World War I, little that was new had been said on delusions in either Germany 58 or France : 9 This is why it was decided to make delusions the theme of the First World Con- gress of Psychiatry held in Paris in 1950. 6°,61 Its roll call included great men like Mayer-Gross, Guiraud, Morselli, Rfimke, Delgado, Ey, Gruhle, Minkowski, Stransky, and Baruk. The Paris

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HISTORY OF PREDELUSIONAL STATE 257

meeting did not generate new ideas, but re- hearsed some of the old ones. Based on the writings of Monakow and Mourgue, Guiraud offered a "biological model" according to which delusions resulted from a failure of "primordial psychological activity (atteinte de l'activit~ psy- chique primordial) distorted and masked by human cognitive and affective superstructures" (p. 37). 60 The primordial activity included the feelings of existence, nutrition, reproduction, vigilance, and growth. The self controlled such feelings orpulsions and satisfied them according to the rules of reality and logic. Focal or diffuse pathologic changes in the brain caused selective or global failures (une anomalie partielle ou globale du dynamisme psychique primordial), which in turn might lead to a collapse in the logical organization of the self (p. 40).6°

Gruhle reasserted a definition that, since Hagen, had predominated in German psychia- try: "delusion is an interpretation without rea- son, an intuition without cause, a mental atti- tude without basis. It represents neither sublimated desires nor repressed wishes but is a sign of cerebral dysfunction. It is not secondary to any other phenomenon and has no relation- ship to the patient's constitution" (pp. 112- 113). 61

Mayer-Gross stated that the choice of delu- sions as a theme for the Congress was "appropri- ate," for there was a "relatively low ebb of interest in the psychopathology of delusions" (p. 59). He noted that the conventional defini- tions were unhelpful in practice, and suggested two ways of surmounting this difficulty: "one can call a delusion pathological or, as Bumke put it, an error of morbid origin; or one can insist that delusions do not differ from other human beliefs in principle, that no line of demarcation exists." As Bleuler, 2° whose views have so widely influenced psychopathologic thinking all over the world, has pointed out, "delusional ideas correspond to and are di- rected by the patient's affects and emotions" (pp. 60-61). 60

Morselli 6° attempted a review of the neurobio- logic bases of some delusional states, but did not go beyond listing toxic and metabolic states. Rfimke undertook an analysis of the symptom delusion, which he defined from the phenomeno-

logic point of view as an "artificial abstraction" (p. 182). 6o His contribution was perhaps the most important in that he showed the useless- ness of defining delusions as "beliefs" and also the weakness of the conventional definitional criteria.

SUMMARY

This review has exclusively dealt with the history (up to the 1950s) of the main concepts developed to account for what has been here called the PDS. This was defined as the set of psychopathologic events immediately preceding the crystallization of the delusion and including cognitions, sensations, moods, conations, and motor acts (and combinations thereof). Be- cause of its fleeting and kaleidoscopic nature and opaqueness to analysis, PDS has not been well studied. Nonetheless, as this review has shown, the corresponding clinical phenomena have been described by many great writers and different explanatory models have been put forward; e.g., PDS has been considered a pri- mary disorder of cognition, emotions, conation, and consciousness.

It is also noted that during PDS the patient is expected to report experiences for which, on account of their novelty, he may not even have a name. Thus, it is likely that according to culture and personal codes and to the conceptual brief of the interviewer, similar experiences might be reported as depersonalization, bodily sensa- tions, dysphoria, changes in the perception of reality or time, dissolution of "ego boundaries," etc. There is also lack of agreement as to whether PDS is a unitary or composite experi- ence, primary or secondary, or even related to the delusions that develop in its wake. This results from the fact that it is unknown whether all delusions are preceded by PDS or are the same with regard to their structure and etiology irrespective of the disease in which they are featured (e.g., mania, depression, schizophre- nia, paranoia, organic delirium, etc.). 62 This historic review suggests that PDS is an impor- tant clinical phenomenon, in that it may contain information concerning the early brain changes that assist the genesis of delusions. It is con- cluded that PDS needs to be studied in its own right.

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