Table Of ContentB a s i c r e s e a r c h
Evolution of diagnostic criteria in
psychoses
Thomas A.Ban,MD,FRCPC
Introduction:
from neurosis to psychosis
T
he term neurosiswas introduced to the medical
literature by William Cullen1in the mid-1780s.2Cullen
believed that “life is a function of nervous energy,mus-
cle a continuation of nerve,and disease mainly nervous
disorder,”and classified illness into fever,cachexias,
The term psychosiswas first introduced in the mid-19th local diseases, and neuroses,3 ie, diseases that were
century for the separation of psychiatric disorders from assumed to have their seat in the nervous system.4
neurological disorders within the neuroses. The con- To shift emphasis in the conceptualization of insanity1
cept of psychosis has become gradually restricted from from the nerves to the soul (anima or psyche),the term
a generic term for psychiatric disorders to one of the psychiateriewas introduced by Johann Christian Reil in
major classes of mental illness, which was assumed to 1803.5It was adopted by Johann Christian Heinroth,6
be the result of a disease process, and, more recently, to and changed to psychiatriein his influential text pub-
a symptom present in many psychiatric disorders. In the lished in 1818.Introduction of the term psychiatrypro-
course of this development, the diagnostic criteria for foundly affected the subject matter and the develop-
psychosis shifted from the severity of the clinical man- ment of the field;for well over 100 years,psychiatric
ifestations and the degree of impairment in social func- opinion remained divided as to whether psychiatry deals
tioning to the presence of one or more symptoms in a with Cullen’s1disorders of the nerves (body) or Reil’s5
set of psychopathological symptoms, which include hal- disorders of the soul (mind).7
lucinations, formal thought disorder manifest in disor- The terms neurosis and psychiatry were used inter-
ganized or odd speech, delusions, flat/inappropriate changeably during the second quarter of the 19th cen-
affect, avolition/apathy, disorganized behavior, cata- tury.2Recognition,however,that not every defect of
tonic motor behavior, and depersonalization/dereal- the nervous system was accompanied by mental disor-
ization. The changes in the conceptualization of psy- der led to the introduction of the term psychosis by
chosis and in the diagnostic criteria for psychosis are Ernst Feuchsterleben8in 1845.In his Textbook on Med-
documented in the various editions of the Diagnostic ical Psychology,Feuchsterleben8declared that “every
and Statistical Manual of Mental Disorders of the psychosis is a neurosis,because,without the nerves as
American Psychiatric Association (from DSM-I to DSM- intermediaries,no psychological change can be exhib-
IV) and the International Classification of Diseases of ited,but not every neurosis is a psychosis,”thus using
the World Health Organization (from ICD-9 toICD-10). the term psychosis for the first time in the psychiatric
literature.2
Keywords: case history; classification; diagnostic criteria; disease process; psy-
By separating the disorders of the nerves with mental
chosis; psychotic behavior; severity-based criteria; sociomedical concept; symp-
tom-based criteria pathology from the disorders of the nerves without
Author affiliations: Emeritus Professor of Psychiatry, Vanderbilt University, mental pathology,ie,psychiatric disorders from neuro-
Toronto, Ontario, Canada logical disorders,the concept of psychosis provided the
Address for correspondence: 1177 Yonge Street, Suite 607, Toronto, Ontario, necessary orientation points for the development of the
Canada M4T 2Y4
discipline that we now call psychiatry.9
(e-mail: [email protected])
257
B a s i c r e s e a r c h
The unitary concept of psychosis roses into actual neurosesand psychoneuroses,and Krae-
pelin’s21adoption of the terms psychosis (infection psy-
In the middle of the 19th century,psychosis was an all- choses,exhaustion psychoses,intoxication psychoses,
embracing diagnostic concept,which included all the thyrogenous psychoses,and involution psychoses) and
different general forms of insanity separated by neurosis (psychogenic neuroses) in the sixth edition of
Esquirol,10ie,lypemania (melancholia of the ancient), his Textbook of Psychiatry.Furthermore,by introducing
monomania (partial insanity),mania (pure insanity), his diagnostic concepts of manic depressive insanity and
dementia,and imbecility (or idiocy),and all the differ- dementia praecox in the same edition,he set the foun-
ent mental states described by Griesinger,11ie,mental dation of the Kraepelinian dichotomy of endogenous
depressions (lypemania),mental exaltations (monoma- psychoses,22and opened the path for the division of psy-
nia and mania),and mental weakness (dementia and choses into organicand functional.
imbecility). A further important development in the classification of
Griesinger11perceived psychosis (insanity) as a symp- psychoses was Bonhoeffer’s23separation of exogenous
tom of brain disease and,considering Bayle’s findings or symptomatic psychoses (associated with toxic agents,
that the state of dementia was preceded by a state of infections,or systemic disease) from organic psychoses
monomania and a state of mania in chronic arachnoidi- (associated with course brain disease),ie,dividing the
tis,12he suggested that the various mental states are dif- somatically determined psychoses into organic and
ferent developmental stages of one and the same dis- symptomatic.Another important development was Wim-
ease process.13In his classic text Pathology and Therapy mer’s separation of psychogenic psychoses24(triggered
of Mental Illness,13Griesinger adopted Guislain’s14uni- by psychic trauma or stressful life events) from endoge-
tary concept of psychosis (Einheitpsychose)and postulat- nous psychoses,ie,dividing the functional psychoses into
ed that,in mental syndromes in which neuropathologi- reactiveand endogenous.
cal changes are absent,they will become detectable at a
later stage of disease development.15 Concepts of psychoses
Morel’s theory of degeneration16is in keeping with the
concept of Einheitpsychose, and constitutes the first Psychosis as a disease process
genetic theory of mental illness. It is based on the
assumption that psychosis is the result of an innate bio- In spite of its frequent use,the term psychosis remained
logical defect,which becomes manifest in increasingly vaguely defined9until Jaspers25separated the disease
severe mental syndromes in lineal descents. process from personality development in 1910.Three
Toward the end of the 19th century,Morel’s theory16was years later,in his classic text General Psychopathology,26,27
replaced by Moebius’ endogeny theory,17which implied Jaspers defined psychosis as a disease,which “seizes
only a “constitutionally determined predisposition”for upon the individual as a whole,regardless whether it is
developing psychosis.Nevertheless,genetic anticipa- a hereditary disorder beginning at a certain time of life,
tion—the essential feature of Morel’s16theory—has lin- or a nonhereditary disorder,which is called into being
gered to this day and,in the 1990s,was linked to trinu- by an exogenous lesion.”To qualify for Jaspers’ criteria
cleotide repeat mutations in molecular genetic for psychosis,26the pathological process displayed in a
research.18,19 patient’s case history has to be sufficiently strong to
override normal development,displayed in the life his-
Classification of psychoses tory;and the patient’s behavior has to be sufficiently dif-
ferent that it cannot be understood as an extension of
By the dawn of the 20th century,the concept of neuro- the normal or as an exaggerated response to ordinary
sis—which once embraced both the psychiatric and the experience.
neurological disorders—became restricted to one major Jaspers’26conceptual framework was adopted by Kurt
class of psychiatric disease, and the concept of psy- Schneider28in his rudimentary classification in which
chosis—which once embraced all psychiatric disor- psychoses,ie,the effects of illness,were separated from
ders—became restricted to the other.Instrumental to the abnormal variations of psychic life,ie,anomalies of
this development was Freud’s20separation of the neu- development,which might become manifest in abnor-
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Diagnostic criteria in psychoses - Ban Dialogues in Clinical Neuroscience - Vol 3 .No.4 .2001
mal intellectual endowment,abnormal personality,or illness,pure melancholia,pure mania,pure depressions,
abnormal psychic reactions.Schneider28defined psy- and pure euphorias),cycloid,and schizophrenic,with the
choses as diseases with psychic symptomatology and latter being divided into unsystematic (cataphasia,
somatic etiology,and divided psychoses into somatically affect-laden paraphrenia,and periodic catatonia) and
determined psychoses,cyclothymia (the term he used for systematic (paraphrenias [ie,phonemic,hypochondria-
Kraepelin’s21 manic depressive insanity),and schizo- cal,confabulatory,grandiose,fantastic,and incoherent],
phrenia,29a term he retained in spite of his belief that hebephrenias [ie,autistic,eccentric,shallow,and silly],
“there is nothing to which one could point as a common and catatonias [ie, parakinetic, proskinetic, speech
element in all the clinical pictures”subsumed under this prompt,speech inactive,manneristic,and negativistic]).32
diagnostic category.
Psychosis in consensus-based
Sociomedical concept of psychosis classifications
Jaspers’26concept of psychosis as a disease was trans- To overcome the difficulties created by using different
formed into a sociomedical conceptby Fish30with con- diagnostic criteria for the same diagnostic terms by dif-
sideration that the characteristic features of psychosis ferent schools of psychiatry and in different cultures
include psychopathological manifestations,such as lack and language areas, consensus-based classifications
of insight,distortion of the whole personality by the ill- were developed by the World Health Organization
ness,construction of a false environment out of subjec- (WHO)37-39and the American Psychiatric Association
tive experiences, and gross disorder of basic drives, (APA).40-44A consensus-based classification is a set of
including self-preservation,coupled with an inability to diagnostic formulations agreed upon by a body of expe-
make a reasonable social adjustment. rienced and well-informed psychiatrists.45
The interaction between psychopathology and social
adjustment was further elaborated in the Diagnostic DSM-I
Criteria for Research (DCR) Budapest-Nashville,31in
which psychosis was defined as a nonspecific syndrome The first consensus-based classification with a descrip-
characterized by lack of insight and psychopathological tion of diagnostic terms was the first edition of the
symptoms of sufficient severity to disrupt everyday APA’s Diagnostic and Statistical Manual of Mental Disor-
functioning with collapse of the customary social life, ders (DSM-I)published in 1952.40It was based on Adolf
which may call for psychiatric hospitalization.In the Meyer’s46psychobiological view that mental disorders
DCR,psychosis is the nadir in the process of psychiatric represent reactions of the personality to social,psycho-
illness,the point at which the patient’s case history (ie, logical,and biological factors,and that psychoses are
pathological process) displayed in psychopathological whole reactions,unlike the other psychiatric disorders,
symptoms,such as hallucinations or autism,becomes which are only part reactions.47,48
dominant over the patient’s life history (ie, normal Mental disorders in DSM-Iare divided into two—or
development).During psychosis,there is a forced with- three with the inclusion of mental deficiency—classes of
drawal from everyday life,accompanied by a tendency illness:(i) organic disorders,caused by or associated
to suspend social adjustment,and during the period of with impairment of brain tissue function;and (ii) disor-
hospitalization,social adjustment may collapse to the ders of psychogenic origin or without clearly defined
extent that it may not be possible to assess social adjust- physical cause or structural changes in the brain.Psy-
ment at all.Without encountering such a nadir at least chotic disorders,including involutional,affective (manic
once in the course of the illness,the prerequisite for a depressive reactions and psychotic depressive reac-
DCR diagnosis of psychosis is not fulfilled. tions),schizophrenic,and paranoid reactions,are one of
In the DCR, psychoses are divided into somatically the five categories in the second class.
determined and functional. Functional psychoses are In DSM-I,40psychotic disorders are defined as diseases
divided into reactive24,28and endogenous32with the delu- characterized by personality disintegration,failure to
sional psychoses33-36in between.Endogenous psychoses test and evaluate correctly external reality,and inability
are divided into affective (including manic depressive to relate effectively to people or work.In affective reac-
259
B a s i c r e s e a r c h
tions,the psychosis is characterized by severe mood dis- inappropriate emotional responsiveness, and loss of
turbance, with the mood alterations of thought and empathy with others. Behavior may be withdrawn,
behavior in consonance with affect.In schizophrenic regressive,or bizarre.In paranoid states,a delusion,gen-
reactions,the psychosis is defined by fundamental dis- erally persecutory or grandiose,is the essential abnor-
turbances in reality relationships and concept formation mality and the disturbances in mood, behavior, and
with associated affective,behavioral,and intellectual thinking,including hallucinations,are secondary to this
disturbances marked by a tendency to retreat from real- primary pathology.Organic conditions can be classified
ity,regressive trends,bizarre behavior,disturbances in as psychosis only if the patient is psychotic during the
the stream of thought,and delusions. episode in which the diagnostic evaluation is made.
In addition,the qualifying phrase,“with psychotic reac-
tion,”is used in DSM-Ito amplify the diagnosis of any ICD-9
psychiatric disorder with clinical manifestations that ful-
fill the criteria for psychosis. The first consensus-based classification of the WHO38
with a description of diagnostic terms was the mental
DSM-II disorders section of the 9th revision of the Internation-
al Classification of Diseases (ICD-9)published in 1977.
The second consensus-based classification with a It is based on the division between psychotic disorders
description of its diagnostic terms was the DSM-II,41 and nonpsychotic disorders introduced in ICD-8,37and
published in 1968.It was based on the eighth revision of adopted in DSM-II.41 The definition of psychosis in
theInternational Classification of Diseases (ICD-8)of the ICD-938was,in turn,adopted from DSM-II.41
WHO,37with a glossary of definitions added to the clas- Unlike DSM-II,41there is a clear separation of organic
sification by the American contributors. and nonorganic psychoses in ICD-938with the organic
In DSM-II,41mental disorders are divided into two—or syndromes characterized by impairment of orientation,
three with the inclusion of mental retardation—classes memory,comprehension,calculation,learning capacity,
of illness:(i) psychoses;and (ii) neuroses,personality and judgment.Other organic features include shallow-
disorders, and other nonpsychotic mental disorders. ness and lability of affect, persistent disturbance of
Included among the psychoses are organic conditions mood,lowering of ethical standards,exaggeration of old
(senile and presenile dementia,alcoholic psychoses,psy- and emergence of new personality traits,and diminished
choses associated with intracranial infection,other cere- capacity for independent decisions.The term delirium
bral conditions,and other physical conditions),affective defines one set of organic psychoses in which the char-
psychoses,schizophrenia,and paranoid states. acteristic features of organicity are overshadowed by
In the DSM-II,41psychosis is defined as a mental disor- clouded consciousness,confusion,disorientation,delu-
der in which mental functioning is impaired to the sions,illusions,and vivid hallucinations;and the term
degree that it interferes with patient’s ability to meet the dementia defines another set of organic psychoses,which
ordinary demands of life and recognize reality.Halluci- are chronic,progressive,and,if untreated,irreversible.
nations and delusions may distort perceptions;alter- While the definitions of affective psychoses and paranoid
ations of mood may affect the capacity to respond states are the same in ICD-938and DSM-II,41the scope of
appropriately;and deficits in perception,language,and other nonorganic psychoses in ICD-938is restricted to a
memory may interfere with grasping situations effec- small group of psychotic conditions,which are largely or
tively.In affective psychoses,it is the disorder of mood, entirely attributable to recent life experiences.The defi-
either extreme depression or extreme elation,that dom- nition of schizophrenic psychoses is also changed to
inates mental life and is responsible for the patient’s loss include Kurt Schneider’s49first rank symptoms.Thus,
of contact with the environment.In schizophrenia,char- schizophrenic psychoses are defined in ICD-938 as a
acteristic disturbances of thinking,mood,and behavior group of psychoses with a fundamental disturbance of
dominate.The disturbances of perception and thinking personality,a characteristic distortion of thinking,a sense
are marked by hallucinations and alterations of concept of being controlled by alien forces,delusions which may
formation,misinterpretations,and delusions.Corollary be bizarre,disturbed perceptions,abnormal affect,and
mood changes include ambivalent, constricted, and autism.In schizophrenic psychoses,the disturbance of
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Diagnostic criteria in psychoses - Ban Dialogues in Clinical Neuroscience - Vol 3 .No.4 .2001
personality involves those basic functions that give each induced psychotic disorder;and the term affective dis-
person a feeling of individuality,uniqueness,and self- orders was replaced by mood disorders.
direction.The most intimate thoughts,feelings,and acts
are often felt to be known to—or shared by—others and ICD-10and DSM-IV
explanatory delusions may develop to the effect that nat-
ural or supernatural forces are at work to influence The traditional division between psychosis and neurosis
thoughts and actions in ways that are often bizarre.Hal- is also dismissed in ICD-10,39which was introduced in
lucinations,especially of hearing,are common and may 1992 to replace ICD-9.38The term psychotic was retained
comment on or address the patient. in ICD-1039only as a convenient descriptive term,which
simply indicates the presence of certain symptoms,such
DSM-IIIand DSM-III-R as hallucinations,delusions,gross excitement and over-
activity,marked psychomotor retardation,and cataton-
In 1980,DSM-II41was replaced by DSM-III,42the first ic behavior in some of the psychiatric disorders.Never-
consensus-based classification with a multiaxial evalua- theless, it is also used in the diagnosis of a newly
tion and operationalized diagnostic criteria.In DSM- introduced category of illness,acute and transient psy-
III,42all traditional dichotomies,eg,organic versus func- chotic disorders,in which psychotic symptoms are the
tional, psychotic versus neurotic, are dismissed, and prevailing feature of the clinical picture.
psychiatric syndromes are assigned to one of 15 cate- Similar to ICD-10,39in the DSM-IV,44which was pub-
gories of disease.All the different syndromes in three of lished in 1994,the diagnosis of psychosis is no longer
these categories,ie,schizophrenic disorders,paranoid based on the severity of the functional impairment,ie,
disorders,and psychotic disorders not elsewhere classi- on gross interference with the capacity to meet ordinary
fied,and some of the syndromes in two of the other cat- demands of life,but on the presence of certain symp-
egories,ie,organic mental disorders and affective disor- toms.Included among these symptoms are delusions
ders,qualify as psychotic disorders. and hallucinations (with the hallucinations occurring in
In DSM-III,42the term psychotic is used to describe a the absence of insight into their pathological nature),
patient at a given time,or a mental disorder in which at prominent hallucinations (perceived by the patient as
some time during its course all patients with the disor- hallucinatory experiences), and some other positive
der evaluate incorrectly the accuracy of their percep- symptoms,such as disorganized speech and grossly dis-
tions and thoughts,and make incorrect inferences about organized or catatonic behavior.
external reality,even in the face of contrary evidence.
However,the term psychotic does not apply to minor Diagnostic criteria: past and present
distortions of reality that involve matters of relative
judgment,but gross impairment of reality testing and There has been a gradual shift in emphasis in the diag-
the creation of new reality.Thus,a depressed person nostic criteria for psychosis.While in the past,ie,prior to
who underestimates his/her achievements would not the introduction of the DSM-III,42the diagnostic criteria
qualify as psychotic,whereas one who believes he/she for psychosis were based on the degree of the severity
caused a natural catastrophe would qualify.Direct evi- of the clinical manifestations,and on the interference of
dence of psychotic behavior is the presence of either the manifestations with social adaptation,today’s diag-
delusions or hallucinations without insight into their nostic criteria for psychoses are based on the presence
pathological nature and/or grossly disorganized behav- of certain psychopathological symptoms and on the psy-
ior from which a reasonable inference can be made that chotic behavior displayed.
reality testing is markedly disturbed. For well over 50 years,in Campbell’s Psychiatric Dic-
In 1987,DSM-III42was replaced by DSM-III-R43with tionary,47,48psychoses were differentiated from other
some minor modifications relevant to psychotic disor- psychiatric disorders and especially from psychoneu-
ders,for example,the diagnostic term schizophrenic dis- roses by one or more of the following five variables:(i)
orders was replaced by schizophrenia;the term paranoid severity (more severe, intense, and disruptive); (ii)
disorders was replaced by delusional (paranoid) disor- degree of withdrawal (less able to maintain effective
der;the term shared paranoid disorder was replaced by object relationships); (iii) affectivity (emotions are
261
B a s i c r e s e a r c h
qualitatively different from normal or exaggerated not be based on the symptoms that signal psychosis,psy-
quantitatively);(iv) intellect (language and thinking chotic behavior is today perceived as a symptom of many
disturbed,judgment fails,hallucinations and delusions psychiatric disorders.51
appear);and (v) regression (generalized failure of func-
tioning with falling back to early behavioral levels). Concluding remarks
Other frequently used variables in the differentiation
of the psychoses from the psychoneuroses were insight Since the time of the introduction of the term psy-
and sociability (lost in psychoses and retained in psy- chosis for the separation of psychiatric disorders from
choneuroses),personality (wholly involved in psychoses neurological disorders,8 well over 150 years have
and partially involved in psychoneuroses),and uncon- passed.During this time,the concept of psychosis has
scious processes (verbally expressed in psychoses and become restricted from a generic term for psychiatric
symbolically expressed in psychoneuroses).50In current disorders to a symptom present in many psychiatric
diagnostic manuals,psychotic behavior is detected by the disorders.51Recently,a set of psychopathological symp-
presence of one or more of the following psychopatho- toms have been identified that signal the presence of
logical symptoms:hallucinations,formal thought disor- psychosis regardless of the underlying disorder in
der (disorganized or odd speech),delusions (including which the psychotic behavior is displayed.Since all the
disturbances of ego integrity,such as thought insertion, psychotic symptoms identified represent different
thought withdrawal,or feelings of being controlled),dis- aspects of the pathology in the processing of mental
turbances of affect (flat/inappropriate),avolition/apathy, events in the brain,52psychotic behavior with the diag-
alogia,disorganized behavior,catatonic motor behavior, nostic criteria for psychosis may provide suitable end
and depersonalization/derealization.Since the disorders points for neuropsychopharmacological research in the
that qualify for psychosis,and in which psychotic behav- study of the relationship between signal transduction53
ior may be displayed,are differentiated from each other and processing of mental events in the central nervous
by operationalized diagnostic criteria,which may or may system.❑
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Evolución de los criterios diagnósticos en Évolution des critères diagnostiques dans
las psicosis les psychoses
El término psicosisfue introducido a mediados del Le terme de psychosea été introduit pour la pre-
siglo XIX al separarse los trastornos psiquiátricos de mière fois au milieu du 19esiècle afin de différen-
los trastornos neurológicos; ambos trastornos esta- cier les maladies psychiatriques des maladies neu-
ban incluidos dentro de las neurosis. El concepto rologiques au sein des névroses. Le concept de
de psicosis se ha restringido gradualmente desde psychose, à l'origine un terme générique caractéri-
un término genérico utilizado para referirse a los sant les maladies psychiatriques, a vu son utilisation
trastornos psiquiátricos a uno que se aplica a una progressivement limitée à l’une des classes les plus
de las clases principales de enfermedades mentales importantes des maladies mentales considérée
–en este caso representa el resultado de un proce- comme résultant d’un processus pathologique et,
so patológico– y más recientemente a un síntoma plus récemment, à un symptôme présent dans
que puede estar presente en varios trastornos psi- beaucoup de maladies psychiatriques. Au cours de
quiátricos. A lo largo de este desarrollo los criterios cette évolution, les critères diagnostiques de la psy-
diagnósticos de psicosis han variado desde la seve- chose se sont déplacés de la sévérité des manifes-
ridad de las manifestaciones clínicas y el grado de tations cliniques et du degré d’altération du fonc-
deterioro en el funcionamiento social a la presen- tionnement social à la présence d’un ou de
cia de uno o más síntomas dentro de un conjunto plusieurs parmi un ensemble de symptômes psy-
de síntomas psicopatológicos, los cuales incluyen chopathologiques comprenant les hallucinations,
alucinaciones, trastornos formales del pensamien- les troubles du cours de la pensée se manifestant
to que se manifiestan en lenguaje desorganizado par un discours désorganisé ou étrange, les idées
o curioso, delirios, afecto aplanado / inapropiado, délirantes, un affect émoussé ou discordant, une
abulia / apatía, conducta desorganizada, conducta perte de volonté/apathie, un comportement désor-
motora catatónica y despersonalización / desrrea- ganisé ou catatonique et une dépersonnalisa-
lización. Los cambios en la conceptualización de la tion/déréalisation. Les modifications dans la
psicosis y en los criterios diagnósticos para la psi- conceptualisation de la psychose et celles de ses cri-
cosis están documentados en las diferentes edi- tères diagnostiques sont reflétées dans les diffé-
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