Reactive Psychosis: Discrepancy Between Nosological Concepts and Descriptive Categories

ABSTRACT

Reactive psychosis (RP) is a trauma-induced category whose meaning has varied in relation to the role attributed to lived experiences or vulnerable personality. It has long been described in different countries, but seldom investigated under the influence of symptom-based psychiatric classifications. This article aims to examine the development of RP since the early 20th century, outline how it has been incorporated in modern diagnostic classifications, and set out empirical findings. It is likely that variations in terminology and diagnostic practice have affected estimates of the frequency and hampered the validity of RP in earlier studies. To enhance reliability, RP underwent several changes in successive Diagnostic and Statistical Manual of Mental Disorders and ICD versions and was eventually replaced with descriptive categories for short-lived psychotic disorders. Clinical observations during the COVID-19 pandemic attest the durability of RP, but the current categories prove unhelpful in identifying it and have failed to encourage research.

The predictive validity and outcome of ICD-10 and DSM-5 short-lived psychotic disorders: a review and meta-analysis

The ICD-10 Classification of Mental and Behavioural Disorders introduced the category of 'acute and transient psychotic disorders' (ATPDs) encompassing polymorphic, schizophrenic and predominantly delusional subtypes, and the forthcoming ICD-11 revision has restricted it to polymorphic psychotic disorder, while the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) listed 'brief psychotic disorder' (BPD). To assess the predictive validity and outcome of ATPDs and BPD, relevant papers in English, French and German were searched in PubMed and Web of Science. Where possible meta-analysis of prognostic validators (diagnostic stability, course, outcome and response to treatment) was conducted. Fifty studies published between January 1993 and July 2019 were found. The clinical and functional outcome of ATPDs proved better than in schizophrenia and related disorders, but mortality risk is high, particularly suicide, and treatment trials provide little evidence. Meta-analysis of 25 studies (13,507 cases) revealed that 55% (95% CI 49-62) do not change diagnosis, 25% (95% CI 20-31) converted into schizophrenia and related disorders, and 12% (95% CI 7-16) into affective disorders on average over 6.3 years. Subgroup meta-analysis estimated prospective consistency of polymorphic psychotic disorder (55%; 95% CI 52-58) significantly greater than that of the ATPD subtypes with schizophrenic (OR 1.7; 95% CI 1.4-2.0) and predominantly delusional (OR 1.3; 95% CI 1.1-1.5) symptoms. Moreover, the diagnostic stability of BPD (13 studies; 294 cases) was 45% (95% CI 32-50) over a mean 4.2 years. Although these findings indicate that short-lived psychotic disorders have little predictive validity, significant differences among the ATPD subtypes support the revised ICD-11 ATPD category.

Conceptual Issues in Acute and Transient Psychotic Disorders

Short-lived psychotic disorders as currently listed under "acute and transient psychotic disorder," ICD-11 Classification of Mental, Behavioural, and Neurodevelopmental Disorders, and "brief psychotic disorder," Diagnostic and Statistical Manual of Mental Disorders (DSM-5), constitute a point of divergence in the classification of psychotic disorders between the 2 diagnostic systems, which reveals the lack of knowledge about these conditions. Whether this is due to conceptual shortcomings inherent to the categories themselves and which spill over onto research or reflects a mismatch between the diagnostic criteria used and research techniques needs clarification. This study aimed to examine conceptual issues involved in the development of the above categories and shows that little continuity exists between earlier nosological concepts such as bouffée délirante, cycloid psychosis, and reactive psychosis and modern descriptive categories used to classify short-lived psychotic disorders. It seems likely that shortcomings in terms of symptom completeness, specificity, and heterogeneity, in addition to changes in definition and diagnostic criteria in successive DSM and ICD versions, have hampered empirical research, making it difficult to enhance the understanding of these conditions and achieve a closer concordance between the 2 classificatory systems.

Classic Text No. 128: Thomas Brown's comments on Erasmus Darwin's view on madness

In his book Observations on the Zoonomia of Erasmus Darwin MD, Thomas Brown included a critical chapter on the analysis of madness proposed by Darwin in Zoonomia. Although neither Darwin nor Brown are ground-breaking in their views on madness, they illustrate the transitional accounts of madness that were being entertained at the end of the eighteenth century, particularly among writers who had studied at Edinburgh University.

Classic Text No. 126: 'Some main features in the history of the paranoid illness forms', by Aa. Thune Jacobsen (1921)

Since its construction in Classical times, the meaning of 'paranoia' has changed at least three times. Important gaps still interrupt its long chronology, and more studies of specific clinical and cultural usages are needed before its total history is put together.

'My insanity in the year 1783', by C.S. Andresen (1801)

The literature of the past has included self-reports by the mentally ill since before Roy Porter reminded us that their views and experiences constitute an important document for historians of psychiatry. The value of these self-reports can be enhanced if their potential biases and informational power are duly determined. This Classic Text concerns a self-report of a form of periodic madness written by an eighteenth-century Danish vicar. It shows how the same document can be presented in a more or less neutral fashion by a medical historian (Maar) or used as 'evidence' for some 'ontological' view of madness by a clinician (Rasmussen).

'Insanity in Classical Antiquity', by JL Heiberg (1913)

Heiberg's 1913 text on psychopathological concepts and terms in classical times remains important because of its freshness and historiographical value. A philologist and classical scholar, he seemed puzzled by the assumption of nosological continuity between classical categories of madness and current ones that prevailed at the time among historians of medicine and psychiatry. Heiberg's text acts as a bridge or transition between the nosological antiquarianism of the 19th century and histories of psychiatry that later warned of the dangers of an anachronistic reading of earlier medical texts. It also shows how important has been the contribution of classical philologists to the study of the history of madness. To our knowledge, this is the first rendition into English of the complete Danish work.

Assessing irritability in patients with stroke: psychometric properties of the Irritability Questionnaire

Objective: Irritability is a very common symptom after stroke and a source of a great deal of distress to patients and caretakers. We evaluated the psychometric properties of the Irritability Questionnaire (IQ) in a sample of patients with stroke.Methods: we recruited 94 participants (47 stroke patients and 47 healthy controls) that participated in a 6-month longitudinal observational study. The IQ includes three dimensions in the assessment: emotion, cognition, and behavior. IQ has two subscales: The Irritability Questionnaire (IRQ) and the Carer's Irritability Questionnaire (CIRQ). Internal consistency, convergent validity, and sensitivity to change were evaluated for both IRQ and CIRQ.Results: Cronbach's alpha for the IRQ was 0.91 (95% CI: 0.76 to 0.87), whereas for the CIRQ was 0.92 (95% CI: 0.89 to 0.94). Convergent validity was good for both subscales. IRQ did not show sensitivity to change at 6 months (p-value = 0.99), while CIRQ showed moderate changes (-0.29, p-value = 0.124).Conclusions: IQ presented good psychometric properties to assess irritability in stroke. The tool detected significant differences between groups (stroke and healthy controls) and can be considered a valid instrument for clinical and research purposes.

From Evolutive Paranoia, by August Wimmer (1902)

Literature on the history of 'paranoia' (as a clinical concept) is large and confusing. This is partly explained by the fact that over the centuries the word 'paranoia' has been made to participate in several convergences (clinical constructs), and hence it has named different forms of behaviour and been linked to different explanatory concepts. The Classic Text that follows provides information on the internal clinical evolution of the last convergence in which 'paranoia' was made to participate. August Wimmer maps the historical changes of ' Verrücktheit' as it happened within the main European psychiatric traditions since the early 19th century. After World War II, that clinical profile was to become reified and renamed as 'delusional disorder'.

Historical and conceptual aspects of motor disorders in the psychoses

Historical epistemology is a useful method to understand the longitudinal construction of the movement disorders in psychiatry. Four periods can be identified in such a process. The first, extending from Classical times to the work of Griesinger, included disorders such as catalepsy, crocidism, epilepsy and paralysis. The second period, stretching from Griesinger to Kahlbaum, concentrated on the study of melancholia attonita, stupor and catatonia. The third period, covering the time from Kahlbaum to WWI, witnessed important conceptual shifts such as: the transformation of madness into psychoses; the redefinition of movement and motility in psychiatry; the appearance of self-contained syndromes as dyskinesias, tics, akathisia, complex disorders like the cases of encephalitis lethargica, etc.; the advent of functional and psychodynamic explanations; and the description by Wernicke, Kleist and others of the motility psychoses. The fourth period stretches from WWI to the present and since it corresponds to the views and work reported in the rest of this Special issue it has not been touched upon in this paper. In spite of an increasing methodological refinement, empirical research is yet to clarify what is the clinical meaning of the movement disorders in the context of the psychoses and to explain whether such disorders are primary (i.e. issuing directly from the brain and parallel to the rest of psychotic symptomatology) or secondary (i.e. mediated by cognitive and emotional phenomena characteristic of the psychoses).

'Brain Disorders', by Henry Calderwood (1879)

Henry Calderwood, a nineteenth-century Scottish philosopher interested in madness, published in 1879 an important work on the interaction between philosophy of mind, the nascent neurosciences and mental disease. Holding a spiritual view of the mind, he considered the phrase 'mental disease' (as Feuchtersleben had in 1845) to be but a misleading metaphor. His analysis of the research work of Ferrier, Clouston, Crichton-Browne, Maudsley, Tuke, Sankey, etc., is detailed, and his views are correct on the very limited explanatory power that their findings had for the understanding of madness. Calderwood's conceptual contribution deserves to be added to the growing list of nineteenth-century writers who started the construction of a veritable 'philosophy of alienism' (now called 'philosophy of psychiatry').

Historical epistemology of the body-mind interaction in psychiatry

This paper deals with the history of the relationship between the mind-body dualism and the epistemology of madness. Earlier versions of such dualism posed little problem in regard to the manner of their communication. The Cartesian view that mind and body did, in fact, name different substances introduced a problem of incommunicability that is yet to be resolved. Earlier views that madness may be related to changes in the brain began gaining empirical support during the 17th century. Writers on madness chose to resolve the mind-body problem differently Some stated that such communication was not needed; others, that mind was a redundant concept, as madness could be fully explained by structural changes in the brain; and yet others described psychological spaces for madness to inhabit as a symbolic conflict. The epistemology of the neurosciences bypasses the conundrum, as it processes all together the variables representing the brain, subjectivity, and behavior and bridges the “philosophical” gap by means of correlational structures.

Albert Lemoine and the epistemology in psychiatry

Abstract In 1862, the French philosopher Albert Lemoine (1824-1874) published one of the earliest books on the philosophy of psychiatry and psychopathology. Although brought up as a Spiritualist thinker in the mould of Maine de Biran and Royer-Collard, he attempted to reconcile the speculative neurobiological account of madness predominant in his time (particularly amongst alienists interested in its medicalization) with a broader approach that conceived of the mind as a psychological space populated by dynamic forces and elements also relevant to the causality and meaning of madness. In the ongoing debate on whether Psychology or Physiology was the most appropriate science for the study of Madness he rightly stood in the middle. His views remain important for the issues that he dealt with have not yet been resolved.

'Motility Psychoses', by Erik Strömgren (1940)

The motility psychoses are a group of acute psychiatric conditions characterized by salient disorders of movement (increased, decreased and disorganized), psychotic experiences, confusion and good prognosis. The debate on whether they are just atypical forms of schizophrenia or manic-depressive insanity or constitute an independent group of psychoses has not yet been settled. Erik Strömgren's classical chapter deals with the history and clinical aspects of the motility psychoses. Based on a historical analysis and an empirical study of a patient cohort, the author draws conclusions on the nature of this clinical group that has stood the test of time well.

Research in Psychiatry: Concepts and Conceptual Analysis

Current research in psychiatry is increasingly focused on empirical studies with methods and technologies adopted from medicine. This paper argues that psychiatry has a different epistemological basis from medicine, and it is on account of this that research in psychiatry demands a different approach, one that perforce focuses on the clarification of concepts central to psychiatric practice. This means undertaking conceptual analysis and conceptual history and only then moving on to empirical study. This paper highlights the crucial epistemological differences between the practice of medicine and psychiatry, showing that the latter is enacted at the level of language and communication. Consequently, the structures of psychiatric objects, namely, mental disorders and mental symptoms, are complexes of meaning derived from heterogeneous sources - both organic and semantic. Conceptual analysis of such structures is essential as ultimately the validity of empirical research is directly dependent on the conceptual clarification of its objects of inquiry.

The 'Preliminary Discourse' to Methodical Nosology, by François Boissier de Sauvages (1772)

The eighteenth century witnessed an intense drive to classify diseases as natural kinds. Together with Linné, Macbride, Cullen, Sagar and Vogel, François Boissier de Sauvages, Professor of Medicine at Montpellier, was an important player in this process. In his monumental Nosologie Méthodique, Sauvages based his nosological system on the more botanico view proposed by Thomas Sydenham, namely, that human diseases (including mental ailments) should be classified in the same way as were plants. Classic Text No. 104 is an abridged translation of the Preliminary Discourse to the Nosologie Méthodique.

David Hartley's views on Madness: With an introduction by GE Berrios

The psychiatric aspects of David Hartley's writings have received less attention than the rest of his work. This Classic Text deals with Section VI of his Observations on Man …, namely, the 'Imperfections of the rational Faculty'. Hartley defines madness as an imperfection of reason that can be temporary or enduring. He makes use of his model of mental functioning to differentiate between eight clinical categories of madness, each representing a different pattern of vibrations of the nerves. Hartley developed this model based on Newton's theory of vibrations and, to explain the complexity of mental acts and entities, he combined it with his own version of the mechanism of Association of Ideas borrowed from John Locke. Much work needs to be done to identify the provenance of Hartley's nosology and nosography.

The construction of anosognosia: history and implications

The construction of anosognosia as a clinical 'disorder' resulted from the convergence (in the work of various writers and culminating in Babinski) of a name, a concept, and a clinical phenomenon. During the early stages of this convergence, unawareness of neurological dysfunction was not considered as an independent clinical phenomenon. Started in the work of Anton, the process of separating it as a differentiable clinical state is completed by Babinski who reaffirmed the semiological independence of 'unawareness'. The history of the construction of 'anosognosia' parallels the late 19th century debate on the nature and brain inscription of the concept of 'consciousness'.

Introdução ao texto clássico de James Sully

O texto clássico a seguir é importante por três razões: é de autoria de James Sully, um dos maiores filósofos-psicólogos britânicos do século XIX; apresenta uma interessante distinção entre os conceitos de ilusão e falácia; e oferece uma advertência velada sobre a eficiência epistemológica do método psicológico da introspecção. Cada um destes pontos serão brevemente tratados nesta introdução.

J.H. Pons on 'Sympathetic insanity': With an introduction by GE Berrios

The ancient concept of 'sympathy' originally referred to a putative affinity or force that linked all natural objects together. This notion was later used to explain the manner in which human beings related and felt for each other. A large literature exists on both the physical and psychological definitions of sympathy. Until the nineteenth century the conceptual apparatus of medicine preserved the view that the organs of the human body had a sympathetic affinity for each other. In addition to these 'physiological' (normal) sympathies there were morbid ones which explained the existence of various diseases. A morbid sympathy link also explained the fact that insanity followed the development of pathological changes in the liver, spleen, stomach and other bodily organs. These cases were classified as 'sympathetic insanities'. After the 1880s, the sympathy narrative was gradually replaced by physiological, endocrinological and psychodynamic explanations. The clinical states involved, however, are often observed in hospital practice and constitute the metier of 'consultation-liaison psychiatry'. Hence, it is surprising that historical work on the development of this discipline has persistently ignored the concept of 'sympathetic insanity'.

'Febrile anxiety', by Robert James (1745): with an introduction by

The current class of psychiatric conditions called 'Anxiety Disorders' was constructed during the 20th century. Before 1900, its clinical components were conceptualized differently: some were not considered as diseases at all and others were looked after by physicians (not alienists). Whether it can be claimed that the complaints included under the 'Anxiety Disorders' have always existed, that is, constitute a form of 'natural kind', is a moot point that needs further historical investigation. This is because psychiatric complaints (mental symptoms) are no more than culturally configured segments of biological or symbolic information. Therefore, symptom-invariance or -perdurance can be explained by either biological or cultural factors. This can only be resolved by studying symptoms individually. Classic Text No. 97 shows how 'Anxiety' was conceptualized during the 18th century.

Sobre Edmund Gurney

O artigo que se segue é importante por ter redirecionado o estudo das alucinações para longe do contexto médico estreito que havia sido construído por Esquirol, Baillarger e Michéa (Berrios, 1996). A morte prematura de seu autor, um homem de Cambridge de raro talento, privou a epistemologia inglesa de um paladino importante.

O desenvolvimento inicial das ideias de Kraepelin sobre classificação: uma história conceitual

A Psiquiatria ainda vive em um mundo kraepeliniano e os estudos sobre a obra de Kraepelin são, por conseguinte, ahistóricos. A exegese seletiva das várias edições de seu tratado levaram a uma visão rígida sobre sua contribuição. No entanto, Kraepelin viveu e escreveu durante um período importante da história intelectual da Europa e sua obra só pode ser entendida neste contexto. Este artigo analisa o desenvolvimento de suas opiniões em termos do "Programa de Pesquisas" que ele planejou precocemente em sua vida e cujo objetivo era a criação de uma descrição estável e da classificação das psicoses. Isso Kraepelin eventualmente alcançou estudando longitudinalmente coortes de pacientes em termos de critérios metodológicos, tais como o curso da doença e a incurabilidade. No caso, esta metodologia permitiu-lhe identificar por correlação "quadros clínicos" que tanto representavam a "essência" da doença quanto forneciam um critério taxonómico. Embora declaradamente ateórico, Kraepelin assim conseguiu construir (influenciado por Kahlbaum e por Wundt) um suporte empírico para sua categorização kantiana das psicoses. Uma discussão sobre as variáveis culturais que moldaram essas ideias está aqui incluída.

Epilepsia e insanidade no início do século XIX - história conceitual

Durante a primeira metade do século XIX, a epilepsia e as insanidades foram consideradas estreitamente relacionadas às desordens "neuróticas". Sob a influência de fatores tais como o declínio do conceito setecentista de neurose de Cullen, o desenvolvimento da nova psicopatologia descritiva, a introdução da estatística e a disponibilidade de observações longitudinais de coortes de pacientes hospitalizados, a epilepsia foi redefinida como uma doença "neurológica" por volta de 1850. A reação da psiquiatria à exclusão do transtorno mental como uma característica definidora da epilepsia se manifestou na criação do conceito de "epilepsia mascarada". Essa noção está por trás do desenvolvimento posterior de categorias como "fronteiriça" e "equivalente", que ainda são de alguma relevância para os pontos de vista quanto à epilepsia no século XX.

Melancolia e depressão durante o século XIX: uma história conceitual

Este artigo analisa historicamente o background ideológico que tornou possível a transformação da noção de melancolia nos conceitos de depressão e transtorno bipolar, a partir das mudanças médicas e psicológicas ocorridas no decorrer do século XIX. A antiga noção de melancolia foi remodelada e sua transição para a doença depressiva foi facilitada pelo conceito de Iipemania de Esquirol, que, pela primeira vez, enfatizou a natureza afetiva primária da doença. Finalmente, uma vez obtidas as condições conceituais necessárias, a melancolia e a mania foram combinadas no conceito de insanidade alternante, periódica, circular, ou de forma dupla, seus rígidos padrões descritivos foram flexibilizados, tendo culminado este processo na sinopse de Kraepelin.

Psicopatologia descritiva: aspectos históricos e conceituais

Este artigo oferece uma análise conceitual e histórica da psicopatologia descritiva. A primeira seção a define como um sistema cognitivo constituído por termos, suposições e regras para a sua aplicação. Traça as implicações conceituais dessa definição e as relaciona à prática clínica. A segunda seção contém uma avaliação do trabalho histórico sobre a psicopatologia descritiva e oferece uma hipótese para explicar o seu desenvolvimento durante o século XIX. Sugere-se que o trabalho envolvido no teste de hipóteses deve ser realizado por psiquiatras com formação em história e enquanto uma especialidade separada. Conclui-se que a calibração histórica dos sintomas psiquiátricos deve ser considerada como uma etapa essencial na construção de uma psicopatologia descritiva viável.

A psicopatologia da afetividade: aspectos conceituais e históricos

Os transtornos do afeto não contribuíram muito para a definição diagnóstica da doença mental, e sua descrição fenomenológica nunca alcançou a riqueza da psicopatologia da percepção ou da cognição. Esse artigo mostra como o papel subordinado desempenhado pela afetividade na concepção ocidental do homem conduziu a uma visão inicial, mas persistente, da doença mental como um distúrbio exclusivo do intelecto. Tentativas dos psiquiatras do século XIX de contestar essa noção foram apenas parcialmente bem-sucedidas, devido às dificuldades de manejo conceitual da maior parte dos comportamentos afetivos e da redundância terminológica que isto engendrava. Esses esforços foram frustrados pelo renascimento do Associacionismo, o surgimento dos experimentos de localização cerebral, a definição periferialista das emoções e, finalmente, pelos desdobramentos do darwinismo. Como resultado, não se desenvolveu nenhuma psicopatologia autônoma da afetividade. O eventual reconhecimento dos assim chamados transtornos "primários" do humor não levou, contudo, a um refinamento na semiologia das próprias experiências. Isso foi impedido pelo uso dos substitutos descritivos comportamentais ou pelas descrições metapsicológicas do afeto como uma forma de energia ou como uma força pulsional. Nenhum desses desenvolvimentos contribuiu para a descrição clínica dos transtornos de humor.

Epistemology of psychiatry

In historical and epistemological terms, psychiatry is a new discipline born during the 19th century. Rooted in both the natural and social sciences, psychiatric objects of inquiry, namely mental symptoms and mental disorders, are hybrid, constituted by the blending of components arising from disparate sources of knowledge ranging from the biological to the semantic in its widest sense. This poses problems for psychiatric research and therapy. Whilst conventional pluralism may be a convenient approach to manage aspects of psychiatric practice, it lacks the capacity to analyse psychiatric objects in their entirety. For the latter, psychiatry demands a new, tailored regional epistemology. This paper outlines the main features of an epistemology specific to the needs of psychiatry. It highlights the relational approach that needs to be taken and illustrates the usefulness of this approach by analysing the structure of psychiatric objects, exploring the manner in which they may be inscribed in the brain, and identifying the need to periodically recalibrate the language of psychiatry.

[Confabulations (II): explicative models]

INTRODUCTION

Confabulations, or the production of false memories without deliberate intent to lie, is an intriguing phenomenon for which an attempt has been made to explain it since they were first described. Confabulations are a good example for illustrating the reconstructive character of memory. Nevertheless, their exact nature and the way in which they are produced are still controversial.

OBJECTIVE

To review the different models proposed to explain the appearance of confabulations.

DEVELOPMENT

Neuropsychological models that currently have some theoretical development and empirical evidence are reviewed. In addition, a brief reference to motivational models, that have recently begun to recover popularity, are presented. We conclude by presenting the last version of the strategic retrieval model that makes it possible to integrate the relevant elements from the others.

CONCLUSIONS

Early models of confabulations, which considered them a result of the need to fill memory gaps, are outdated nowadays. Nevertheless, emotional processes are taken into account to explain their content. From neuropsychological approaches, it is possible to distinguish models that consider confabulation as a result of a temporal or contextual problem, and those which consider that the main problem is on the memory retrieval process. More specifically, the strategic retrieval hypothesis states that confabulations are the result of a dysfunction in a complex system of monitoring the recovered information. This model would make it possible to integrate explanations and evidences coming from the other proposals.

Alucinações táteis: aspectos conceituais e históricos

Uma breve análise histórica do conceito geral de alucinação é apresentada e sugere-se que ela surgiu como a generalização injustificada de um modelo perceptual que estava destinado a ser aplicado apenas para a visão e os "sentidos de distância". Neste contexto, considera-se a evolução das alucinações táteis e explora-se sua interação com a teoria psicológica vigente no século XIX. Conclui-se que as alucinações táteis são fenômenos sui generis que não se encaixam no modelo convencional e que a identificação de seu quadro clínico baseia-se, até o momento, em critérios pouco claros. Apresenta-se uma breve revisão da sua taxonomia e utilidade diagnóstica. Algumas implicações mais amplas são delineadas, as quais podem ser relevantes para a concepção geral da alucinação.

A síndrome de Charles Bonnet e o problema dos transtornos de percepção visual nos idosos

A literatura, clássica ou recente, sobre os transtornos de percepção nos idosos é revisada. A utilidade do conceito de Síndrome de Charles Bonnet, um epônimo originalmente proposto para descrever as alucinações visuais nos idosos na ausência de prejuízos cognitivos e de oftalmopatia periférica é contestada, principalmente devido à síndrome ter sido progressivamente ampliada. Descrevemos três casos representativos de pacientes idosos que desenvolveram diferentes tipos de transtornos de percepção visual. Propomos a condução de estudos sistemáticos da frequência de tais transtornos nos idosos e de quais outras patologias, particularmente cognitivas e visuais que possam estar associadas a eles.

Awareness and insight in psychopathology: An essential distinction?

In psychiatry/clinical psychology, the language of psychopathology remains the main clinical and research tool as it seeks to capture the clinical phenomena underlying mental disorders. It is thus important periodically to review it in order to clarify and refine its relationship to its referent phenomena. This paper argues for a fundamental distinction to be made, in a technical sense, between awareness and insight as, respectively, the narrower and wider form of self-knowledge patients have concerning their conditions.This distinction is based on differences between “objects” of such self-knowledge. Where “objects” refer to impairment of function, as in the neurosciences, the corresponding phenomenon of self-knowledge (awareness) is narrow, based on a direct appraisal of impairment, and evaluated quantitatively . Where “objects” refer to mental symptoms/disorders, as in clinical psychology/psychiatry, the corresponding phenomena of self-knowledge (insight) are wide, based on both direct and indirect appraisals of change, and are evaluated quantitatively and qualitatively. The technical distinction between awareness and insight is important because it differentiates between structural differences in phenomena, indicative of differences in underlying mechanisms, and in turn suggesting the need to adopt different approaches to their study.

Henry Ey, Jackson e as ideias obsessivas

O artigo destaca a importante contribuição do professor de psiquiatria Henry Ey aos estudos sobre John Hughlings Jackson. Analisa historicamente uma interface pouco conhecida de Jackson com a psiquiatria: o diálogo sobre as "ideias obsessivas" que figura nas páginas da revista Brain, entre 1894 e 1895. Discute as razões históricas que podem explicar a não influência de Jackson na psiquiatria britânica, em contraste com a ampla difusão de suas posições no campo da neurologia.

O estupor revisitado

O estupor é uma síndrome negligenciada. Isso pode ser devido à sua baixa incidência, complexidade intrínseca e boa resposta à ECT. A pobreza do material clínico não tem permitido análises estatísticas e científicas adequadas e, portanto, sua fenomenologia e neurofisiologia permanecem não esclarecidas. Questões importantes são: 1) se o estupor constitui uma forma estável de comportamento chegando a ser uma "síndrome complexa"; 2) se ele representa um comportamento pré-programado ou vestigial que pode ser desencadeado por noxa severa, seja psicogênica ou orgânica; 3) se a personalidade e causa subjacente desempenham um papel modulador e 4) se os estupores orgânicos e funcionais compartilham mecanismos subjacentes similares ou, alternativamente, se referem a estados clínicos não relacionados. Um ponto de vista evolucionário deveria integrar os estupores neurológicos e orgânicos e justificar o uso da resposta de "congelamento" ou cataléptica ao estresse em animais como um modelo de pesquisa. Isso deveria, por sua vez, sugerir predições farmacológicas de interesse para o manejo do estupor humano.

Delirium e confusão mental no século XIX: uma história conceitual

O delirium permaneceu uma categoria psiquiátrica estável até o início do século XIX, quando passou por uma redefinição etiológica e fenomenológica, precipitando a transformação das insanidades funcionais em psicoses. A confusão, introduzida pelos franceses ao longo da segunda metade do século, referia-se a uma síndrome mais ampla (porém incluindo) o delirium. Enfatizava o pensamento caótico e as falhas cognitivas. A noção de turvação da consciência (e desorientação temporoespacial) estabeleceu um denominador comum para as duas concepções, enquanto Chaslin e Bonhoeffer redefiniram a confusão e o delirium como as manifestações estereotipadas da insuficiência cerebral aguda.

'On alterations in the form of speech and on the formation of new words and expressions in madness' by L. Snell (1852)

This Classic Text is a translation of an 1852 paper on neologisms and other disorders of language in the insane by Ludwig Snell (1817—92). It illustrates the impact on descriptive psychopathology caused by the early nineteenth-century view that language shaped thought and culture. Developed by Herder, Humboldt and others, this view was to govern the way in which disorders of language were to be studied in psychiatry until well into the twentieth century. After World War II, the so-called ‘cognitive revolution’ returned to the view that thought was more important than language. This encouraged psychiatrists to neglect the study of psychotic neologisms per se and consider ‘thought disorder’ as a primary abnormality in schizophrenia.

The historical roots of Theory of Mind: the work of James Mark Baldwin

The historical development of the concepts underpinning what is currently called 'Theory of Mind' (ToM) has received little attention. This paper deals with the contribution of James Mark Baldwin (1861-1934) whose work on such concepts was original and profound. Embedding his version of ToM into a coherent developmental theory of human cognition, and suggesting novel methods of observation, Baldwin also proposed new conceptual tools and protoconcepts such as the 'ejective-self'. Baldwin also wrote on the distinction between the mental and the non-mental, and on play and imitation. His influence on Jean Piaget, another important figure in the development of ToM, is briefly touched upon here, as are possible explanations for Baldwin's woeful absence from the 20th-century ToM hagiography.

A review of the natural course of bipolar disorders (manic-depressive psychosis) in the pre-drug era: review of studies prior to 1950

A review of the most important original studies describing the natural course of bipolar disorder (manic-depressive psychosis) published in the pre-drug era - before 1950 - is conducted. Discrepancies among studies are detected, most of which are likely explained by methodological differences. However, some conclusions from these old studies remain perfectly valid nowadays: mania is a chronic brain disorder, inherited in most cases, decompensation being more frequent between March and August. It is more common in males, and in some cases, is secondary to other somatic problems. Mixed states are more frequent in the elderly. The review of this type of historical studies is aimed at underscoring the importance that should be attached to the careful study of psychopathology and its recording, both in clinical practice and in psychiatry research.