The predelusional state: A conceptual history

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  • 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

  • 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 reason-- 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 atmosphere. . , 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-

  • 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,

  • 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...