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DOI: 10.1177/0957154X09338086
2010 21: 54 History of Psychiatry
Augusto C Castagnini
Wimmer's concept of psychogenic psychosis revisited

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Wimmers concept of psychogenic
psychosis revisited
Augusto C Castagnini
University of Cambridge
Abstract
In the early twentieth century the Danish psychiatrist August Wimmer (18721937) developed the concept
of psychogenic psychosis (PP) as a category of mental disorders separate from schizophrenia and manic
depression. It subsumed a variety of clinical conditions with affective, confusional and paranoid features
typically triggered by a psychical trauma. Wimmers work has established itself as one of the classic texts
in Scandinavian psychiatry but, for linguistic reasons, long remained almost unknown in other European
countries. Translated into English in 2003, it is now available for historical and psychopathological analyses.
This paper describes the original meaning of PP and sets it in context, then discusses the implications arising
from the usage of the diagnostic categories introduced to replace PP in modern international classifications.
Keywords
history, ICD, psychiatric classification, reactive psychosis, Wimmer
Quon ne dise pas que je nai rien dit de nouveau: la disposition de matries est nouvelle
(Pascal, 1662/1897: Pense 22)
Psychogenic psychoses
In 1916 August Wimmer, then Professor of Psychiatry at the University of Copenhagen, wrote a
book entitled Psykogene Sindssygdomsformer (Psychogenic Forms of Mental Illnesses), which has
influenced generations of Scandinavian psychiatrists but, for linguistic reasons, long remained
almost unknown outside the Nordic countries.
1
This regrettable state of affairs was redressed by the
publication of Schioldanns English edition Psychogenic Psychoses in 2003 (see Castagnini, 2004).
Wimmers book is divided into two parts. The first opens with a definition of psychogenic psy-
chosis (PP), followed by discussions of French and German literature, psychogenic diathesis, the
effects of abnormal emotions, psychical trauma, emotional conflicts and overvalued ideas. The
second part includes a clinical classification of PP illustrated by selected case-histories
2
drawn
from Wimmers patients admitted to the St Hans Hospital, a mental asylum near Copenhagen.
Article
Corresponding author:
A C Castagnini, Department of Psychiatry, University of Cambridge, Cambridge, CB2 2QQ, UK.
Email: acc36@cam.ac.uk
History of Psychiatry
21(1) 5466
The Author(s) 2010
Reprints and permission: http://www.
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DOI: 10.1177/0957154X09338086
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Castagnini 55
Wimmers definition of PP runs as follows: By psychogenic psychoses we will in the following
understand, in accordance with foreign writers, the varied clinically independent psychoses, whose
distinctive feature is that they generally on a (specific) predisposed terrain are caused by psy-
chic factors (psychic traumata) and in such a way that these pathemata are decisive for the time
of eruption of the psychosis, its movements (remissions, intermissions, exacerbations), frequently
also its termination. Likewise, in form and content the psychosis more or less directly and com-
pletely (understandably) reflects the precipitating psychic causal factor. To these criteria we may
further add the predominant tendency of these mental illnesses to recovery, and especially that they
never terminate in dementia (Wimmer, 1916/2003: 87
3
).
Contrary to the Kraepelinian emphasis on clinical pattern and outcome, what Wimmer desig-
nates as PP is a composite trauma-induced category to which subjects are rendered susceptible by
their psychological predisposition. He states that, while the term psychogenic psychosis is perhaps
somewhat unfortunate, and others used reactive psychosis (Bonhoeffer), situational psychosis
(Siemerling) or hysterical insanity (Vogt), it nonetheless represents the superior and far more
comprehensive concept, under which the hysterical psychoses (and neurotic cases) fall with their,
in certain respects, somewhat peculiar symptomatology (p. 90). Wimmer insists that psycho-
genic includes reference to both content and emotional tone of trauma, and is therefore preferable
to ideogenicity, which stresses only the ideational content (lide froid, Janet) (p. 91).
His conception differs from the views of Morel and Magnan, which were based on the idea of a
degenerate constitution leading to increasingly severe manifestations in successive generations
(Bing, 1994). He simply envisages an abnormal psychic vulnerability or an abnormally accentu-
ated resonance ..., which at the same time predisposes the individual to such situations (occupation,
family conditions, etc.), and in which the possibility for such traumata to occur is significantly
increased (Wimmer, 1916/2003: 912). In these individuals, memories of unpleasant experiences
and emotional conflicts are less likely to undergo a process of gradual resolution and lose their
affective charge. Accordingly, they may form complexes of ideas which discharge themselves with
florid psychotic symptoms (delusions, hallucinations, etc.), affect crisis, confusion or negatively
by repression and selective amnesia.
In support Wimmer cites Freud, Janet, Bleuler, Jung and the James-Lange theory of emotions.
He further embraces the concept of catathymia, coined by the Swiss psychiatrist W. M. Maier
(1912), as a general mechanism for psychogenesis. The term catathymia denotes the transforma-
tion of the psychical content by emotive influences, the process of sensitization whereby memories
of past experiences are recollected by events thematically related to them, provoking abnormal
(idiosyncratic) reactions (Wimmer, 1916/2003: 914).
Drawing on Wernickes (1906) notion of overvalued idea (berwerthige Vorstellung), Wimmer
(1916/2003: 138-43) considers the pathological domineering (fixed) idea as the ideo-affective
nucleus from which, either narrowing down consciousness through catathymic association and
selection of psychical material, or by abnormal intensification of the ego-feeling, a circumscribed
(paranoiac) auto-psychosis (delusion of reference, Beziehungswahn) may develop.
Wimmer was also influenced by Reisss (1910) work on reactive depression, but less so by Jaspers
(1913a) concept of true reactive psychosis (echte reaktive Psychose) (Schioldann, 2003).
4
In the first
edition of Allgemeine Psychopathologie, Jaspers (1913a) introduced a methodological distinction
between causal explanation (Erklren) and intuitive understanding (Verstehen), from which the
psychopathological concepts of process and personality development derive (Lanteri-Laura,
1962). His rationale for this distinction was the belief that mental states do not establish causal rela-
tionships, but only delineate meaningful connections that are unverifiable by scientific methods.
Jaspers (1913a) regarded abnormal reactions as phenomena susceptible to understanding in terms
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56 History of Psychiatry 21(1)
of: (a) the extent (Mass) of trauma, (b) meaning (i.e., defence, escape, wish fulfilment), (c) content.
5

However, as pointed out by Starobinski (2003: 215), the actual passage (Umsetzung) into the patho-
logical remains psychologically incomprehensible, and indeed Jaspers (1963) refers to extra-con-
scious mechanisms such as predispositions (Anlagen), concomitant diseases, and alterations in
mental equilibrium consequent on emotional shocks.
According to Wimmer (1916/2003: 88), the intimate connection between cause and effect in
true psychogenic psychoses does not only provide us with the genesis of the mental illness, but
foremost makes the psychosis psychopathologically understandable. Yet referring to Freuds and
Breuers view that hysterics suffer from memories, he went on to state that:
the considerable emotion energy of the psychic trauma and its intimate relationship with the most central
elements of an individuals personality, which conditions the firm memory anchoring, consciously or
subconsciously at the same time explains its pronounced tendency to recur, to be relived in a more or
less paroxysmal manner, and with an emotion energy, a clarity of memory, which is often not inferior to
the strength and vividness of the primary experience. (p. 122)
In later writings, he further remarks that PP appear on a predisposed terrain through the influence
of psychological factors of various kinds Beside this and perhaps rather more important is the
painful inner-psychical conflict (Wimmer, 1924/1993: 42930). The transition from a descriptive
approach to a greater emphasis on psychodynamic concepts will open up the possibility of an
authentic psychoanalytical interpretation (see Frgeman, 1963; Ger, 1943).
There are, however, two caveats. First, the view that PP are an exaggeration of emotional
responses, and differ from the norm only in degree of severity, contrasts with the conventional
meaning of psychosis, which involves qualitative differences not understandable in a psychologi-
cal sense. Secondly, Wimmers concept of psychogenesis assumes a causal relationship between
the affect trauma and the form and content of symptoms that needs to be considered cautiously
because there are reactions without any apparent content (states of stupor, clouding of conscious-
ness, etc.), or inappropriate (paradoxical) in relation to the precipitating situation (funeral mania).
In this connection, Wimmer suggests that The joyless mania appears readily understandable as
an attempt at abreacting, relief from painful inner tension or anxiety similarly to what can be
seen as forced merriness in normal people (Wimmer, 1916/2003: 126).
Another possible criticism arises from cases which Schneider (1959) called sporadic (intermit-
tent) reactions, as they do not run parallel with the actual experience but are triggered by a word
or phrase that evokes memories of unpleasant events.
Psychogenic diathesis
Although the psychical trauma is central to Wimmers view, patients affected with PP are reported
to have a predisposition to experience abnormally strong affects and to re-experience these with
essentially the same strength and further effect on the mental processes (p. 97).
Wimmer mentions two mental dispositions: (a) the explosive-emotional temperament (consti-
tution motive, Dupr; abnorme Affektbereitschaft, Ashaffenburg); and (b) the paranoigenic
temperament. The clinical features released by affect recurrences which impinge on the explosive-
emotional temperament consist of more diffuse and undifferentiated manifestations affect crises,
dystymias, etc. and reflect a more general effect on consciousness simple inhibition, dissocia-
tion, etc. (p. 142) than those associated with the paranoigenic temperament, which involves a
domineering idea, an overvalued idea with quite distinct further effects in consciousness (p. 138).
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Castagnini 57
Wimmer quotes several contentions that atypical forms of paranoia arise from interaction
between a vulnerable disposition and traumatic experiences, and do not ultimately lead to mental
deterioration. These contentions included Magnans dlire des dgnrs, Srieux and Capgras
constitution paranoique as the basis of their dlire dinterpretation, Ziehens paranoid psycho-
pathic constitution, the abortive paranoia as described by Gaupp, the mild forms of paranoia
(Friedmann) and others (Birnbaum, Bonhoffer, Wilmanns, etc.) (pp. 13842).
Kraepelin also depicted paranoia querulans as a deviant form of personality development, list-
ing it within psychogenic disorders (p. 140). He conceded that not all the patients affected with
dementia praecox experienced an unfavourable outcome, but psychosis would only develop from
psychogenic factors if there were a mental predisposition.
In addition to affect trauma and predisposition, Wimmer describes a third category of factors,
concausae, which contribute to the aetiology by intensifying the existing psychogenic diathesis
(p. 155). Among concausae he lists: endogenous processes such as puberty, menopause, masturba-
tion, etc.; exogenous noxae such as head injuries, alcohol abuse, toxic-infective states, physical
exertion, etc.; and purely psychogenic (psychoplastic) attributes (timidity, insecurity, etc.). In some
cases, conditions such as unwanted pregnancy or illegitimate childbirth may per se have enough
emotional impact to occasion abnormal reactions (pp. 1567).
Classification of psychogenic psychoses
Wimmer distinguished two main clinical groups: (a) affective syndromes including psychogenic
depression, psychogenic exaltation and states of stupor; (b) paranoid reactions with predominantly
expansive or persecutory symptoms.
What complicates the classification is that PP are not only polymorphic but also tend to shift
without any apparent discontinuity between the various reaction patterns, for example from affect-
crisis through more persistent clouding of consciousness to hallucinatory confusion and delirium.
This is not surprising because Wimmer drew less attention to issues of classification than he did to
discerning the psychopathological mechanisms responsible for PP. He argued that:
The rather rich and particularly more persistent combination of certain symptoms can point in the direc-
tion of certain more fixed illness pictures. But it is only by means of an in-depth psychopathological
scrutiny of the concrete case of illness, by attempting to understand its genesis, its symptomatological
definiteness, etc., that one can arrive at the right diagnosis with reasonable certainty. (p. 227)
Psychogenic depression may take the form either of affect crises (Raeche) or reactive depressions
(Bonhoeffer, Reiss, Friedmann). Simple states of sad or despaired mood, revolving around some
traumatic event, usually dominate the clinical picture, so they are not easy to distinguish sharply from
dysthymia (p. 161). The symptomatology can be richer, with anxiety, dysphoria, disturbed sleep, hal-
lucinations and hysterical features. These phenomena probably involve a more accentuated emo-
tional temperament (pp. 1625). There also are conditions characterized by obsessionality
(rumination compulsion), depersonalization and hypochondriac complaints that may resemble trau-
matic neurosis (pp. 1718). General feelings of guilt, tendencies to revive past events, psychomotor
inhibition, diurnal variation of mood and early wakening are by contrast less likely in psychogenic
depression than in manic-depression. Other distinctive features of psychogenic depression are feel-
ings of martyrdom and the susceptibility of mood towards external impression and suggestions
(pp. 1678). Such reactive states have an acute onset and blow over quickly with adaptation to the
distressing situation, but there are cases in which the protracted fluctuation of affect and frequent
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58 History of Psychiatry 21(1)
recurrent states last for months, or even for years, as more closely linked series of separate depres-
sive reactions (chronic remitting form) (p. 169).
Psychogenic exaltations, comprising reactive exaltation, the exaltation of desperation (hys-
terical mania), and anger exaltation are significantly rarer than episodes of reactive mania trig-
gered by somatic (head injuries, infectious diseases, etc.) or psychical factors in manic-depressive
patients (p. 179).
Alongside the affective forms of PP are classified psychogenic states of stupor that more fre-
quently follow reactive depression and alternate with perplexity, confusion and clouded conscious-
ness (pp. 1803). They are usually seen in prisoners as confinement reactions induced by detention
and may be accompanied by explosive reactions, hallucinations, persecutory delusions and hysteri-
cal phenomena. Wimmer mentions the autogenic additions which represent the delirious wish
fulfilments in fantasy, the flight into psychosis (Freud) (p. 137).
States of stupor known as emotional paralysis (Emotionslhmung) and other symptoms result-
ing from psychological shock (e.g. nightmares, panic symptoms, vegetative reflex responses) had
already been described in survivors of catastrophic events such as earthquakes (Bltz, Stierlin),
war experiences (Stransky), etc. (p. 120).
A wider psychological interest attaches to paranoid reactions that arise in the wake of less dra-
matic and fairly specific experiences, and are associated with a depressive-persecutory tempera-
ment or an expansive temperament (p. 1478). Examples of persecutory paranoid psychosis are to
be found among the ranks of the querulant, in cases of morbid jealously, sexual persecution (para-
noia sexualis, Krafft-Ebing), and incarceration psychosis (pp. 14954, 21121), while typical
expansive forms are encountered in mythomaniacs (Dupr), pathological liars (Delbrck), eroto-
mania (Esquirols monomanie erotique) and religious insanity (Magnans dlire mistique) (pp.
2226). These disorders tend to develop slowly, lasting for months or even years in the form of
doutes dlirantes or dlire de supposition (Srieux and Capgras, Tanzi).
The sudden onset of more elaborate delusional ideas (Magnans dlire demble, Bonhoffers
pathologischer Einfall) is often triggered by stressful events through a catathymic mechanism, or
brought about by concomitant conditions such as the effects of alcohol, physical illnesses, insomnia
and the like (p. 145). Paranoid reactions are characterized by sterility, their relative superficiality,
and their susceptibility to outside influence in the way of mobility, inconstancy, transitoriness,
or vice versa, their polymorphism through fantastic re-creations, pathological associations, con-
fabulations, wish-fulfilment in fantasy, memory falsifications, etc. (p. 210), resembling bouffes
dlirantes.
6
Wimmer regards them neither as direct expressions of the paranoigenic temperament
nor of overvalued ideas, rather as delirious phases released by an explosive-emotional tempera-
ment (pp. 146, 211). Although the prognosis of reactive paranoid psychoses is expected to be
favourable, the risk of recurrence is ever present and residual paranoid ideas may persist
(Residurwahn) (p. 231).
PP remain a diagnosis of exclusion from manic-depressive insanity, schizophrenia and para-
phrenia (p. 228), and subsume conditions such as reactive depression, obsessional disorder and
hysteria that would be indicated as neuroses since their separation from psychoses had yet to be
carried out (Berrios, 1987).
The development of psychogenic psychoses
Since its inception in the work of Wimmer, the concept of PP has been readily accepted and further
developed in Scandinavian countries, where in the late 1970s up to a third of psychiatric admis-
sions with functional psychoses were diagnosed as psychogenic or reactive (Dahl, 1987).
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Castagnini 59
Referring to Schneiders (1927) abnormen seelischen Reaktionen, Strmgren (1974) described
three different clinical forms: emotional syndromes with depressive or manic features, disorders of
consciousness, and reactive paranoid psychoses (Table 1). For their respective determinants he
envisaged: situational conflicts, events influencing the perception of environment, and events
affecting the self-image.
In Norway, PP were regarded as functional disorders and not typically schizophrenic, manic-
depressive or paranoid (degrd, 1968). Retterstl (1966: 235) stated that:
The more severe the blow to the personality consciousness, the more paranoiac or pure paranoid seemed
to be the pathological picture The more situational the trauma and the less the personality conscious-
ness seemed affected, the greater appeared the chance of the affective component dominating the psy-
chotic picture.
Langfeldt (1939), in turn, used the term schizophreniform states to denote a group of schizophre-
nia-like disorders that had rapid remission in response to shock treatments. Since Langfeldts work,
clinical features such as acute onset, precipitating stress, mental confusion, prominent affective
symptoms, and extroversion rather than schizoid personality have identified a broad group of
patients whose condition is distinct from schizophrenia in course and outcome (Kant, 1941;
Menuck et al., 1989; Vaillant, 1964).
It was at Strmgrens suggestion that Frgeman undertook a follow-up study of Wimmers
patients admitted to the Municipal Hospital of Copenhagen in 192426. This work was reissued in
English only in 1963, when Frgeman was a Freudian psychoanalyst. He emphasized the catathy-
mic mechanism of psychogenesis, a kind of psychic allergy developed in response to early trauma-
tisms (infantile loss, separation from loved ones, etc.) or repeated frustrations, whereby a seemingly
insignificant event will precipitate a large amount of excitation, that is, anxiety (Frgeman, 1963:
15). The diagnosis of PP was confirmed in 79 of 160 cases, 56 tended to change mainly either to
schizophrenia or manic-depression, and 25 remained uncertain. Nearly 70% of the total recovered,
20% relapsed, and 10% had residual symptoms or a chronic outcome. Emotional and confusional
reactions proved to be more stable and fared better than reactive paranoid psychoses.
Table 1. Scandinavian psychogenic psychoses (Frgeman, 1963; Strmgren, 1974)
Clinical types Nosological concepts
Emotional reactions Psychogenic depression
Psychogenic excitation
Paradoxical reactions: funeral-mania, Emotionslhmung
Temper tantrums, hysterical reactions (amnesia, fugue, etc.)*
Disorders of consciousness Delirious reactions
Dissociative states, depersonalization, twilight states, Ganser
syndrome, multiple personality
Paranoid states Kretschmers (1918) sensitiver Beziehungswahn, litigious paranoia, Allers
(1920) syndrome, prison psychosis, paranoid reactions of deaf people,
induced psychosis (folie deux, folie trois, etc.), wahnhafte Einbildungen
(Birnbaum, 1908)
*Transitional forms to disorders of consciousness.
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60 History of Psychiatry 21(1)
Slater (1964), however, argued that: Frgeman had taken little account of possible organic cau-
sation in 10% of patients; the diagnosis of endogenous psychosis could not be excluded in 5
cases; and no psychological factors were mentioned for a further 9 cases. From a theoretical stand-
point, a number of reactive depressions and dissociations of consciousness which Slater said
would be accepted as psychogenic by psychiatrists of any school were so different in terms
of personality background, outlook and treatment that it is difficult to include them into the same
diagnostic group.
Subsequent studies have failed to validate the view that PP refer to a relatively homogenous
category separate from schizophrenia and manic depression
7
(Jrgensen and Mortensen, 1988;
McCabe, 1975; Noreik, 1970; Opjordsmoen, 1988; Retterstl, 1970). As pointed out by Roth
(1990), Retterstls concept of reactive paranoid psychosis embraced syndromes such as paranoia
and paraphrenia that are closely related to schizophrenia.
Outside the Nordic countries, PP were accepted in Japan, the former Soviet Union and in some
developing countries (Manschreck and Petri, 1978), but made little headway in Continental
(European) and British psychiatry, where their diffusion was hindered by Schneiders (1959) influ-
ential view that all the psychoses are assumed to have a somatic nature and by definition are not
reactive to life experiences. Distinguishing between psychic reaction and psychosis became one
of the main issues in psychiatry after World War II, with significant implications for diagnostic
classification (Cooper, 1986; Gabriel, 1987; Taylor, 1994).
Aubrey Lewiss (1934) work on melancholia, which lent support to the unitary view against the
separation of reactive depression, and Slaters (1964) critical review of Frgemans book contrib-
uted to causing the neglect of PP in Anglophone psychiatry. Lewis (1972) later suggested that
psychogenesis should be given a decent burial.
Psychogenic psychoses and modern classifications
The World Health Organization first introduced PP under Other psychoses in the 8th revision of
International Classification of Diseases, listing them as psychotic conditions attributable to a
recent life experience (ICD-8; WHO, 1967). These comprised: Reactive depressive psychosis,
Reactive excitation, Reactive confusion, Acute paranoid reaction and Reactive psychosis
unspecified. However, as set out in the British glossary issued for use with ICD-8, reactive psy-
choses introduced at the urging of Scandinavian psychiatrists were described in terms that amounted
to an invitation to ignore them (Kendell, 1990: 145).
The development of IDC-9 was preceded by a series of international seminars, the WHO
Programme A 196572, in which participants took part in diagnostic exercises based on selected
case histories and video recordings of interviews with patients. The second meeting, held in Oslo
in 1966, concentrated on psychotic disorders mainly labelled as reactive in ICD-8 (Astrup and
degrd, 1970). It seems likely that the controversy which arose between the WHO experts and the
Scandinavian psychiatrists invited to attend the seminar led the draftsmen of ICD-9 to restrict the
definition of reactive psychoses to the small group of psychotic conditions that are largely or
entirely attributable to a recent life experience (WHO, 1978).
More recently, to eliminate aetiological implications, ICD-10 (WHO, 1992) created a new cat-
egory, F23 Acute and transient psychotic disorders (ATPD), which subsumes clinical concepts of
European psychiatry such as bouffe dlirante (France), cycloid psychosis (Germany; see Kleist,
1928; Leonhard, 1957), and the Scandinavian psychogenic and schizophreniform psychoses. It
was stated that The limited data and clinical traditions do not give rise to concepts that can be
clearly defined and separated from each other. (WH0, 1992). Three features were to identify
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Castagnini 61
ATPD: (a) acute onset; (b) early remission; and (c) presence of polymorphic, schizophrenic or
predominantly delusional syndromes.
8
Complete recovery within 1 or 3 months differentiates,
respectively, ATPD from schizophrenia and persistent delusional disorder.
The issue of psychological reactivity has received little attention; an additional diagnostic code
(F23.x1) may be used to indicate whether each subcategory is associated with acute stress. ICD-
10 defines acute stress as events that would be regarded as stressful to most people in similar
circumstances (bereavement, unexpected loss of partner or job, etc.), occurring less than two weeks
before the onset of psychotic symptoms.
The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric
Association has, since its fourth edition (DSM-IV, 1994), included a similar, yet not identical,
category, Brief psychotic disorder, which may follow or not marked stressors. This statement
has been criticized as meaning that some precipitating event is presumed but cannot be detected,
or else that a condition rather different from reactive psychosis is being described (Munro,
1999).
PP encompassed a broader variety of syndromes than ATPD did (Bertelsen, 2006; Strmgren,
1994). Reactive paranoid psychoses (and schizophreniform states) are now listed as subcategories
of ATPD associated with acute stress: F23.1 Acute polymorphic psychotic disorder with symp-
toms of schizophrenia, F23.2 Acute schizophrenia-like psychotic disorder and F23.3 Other
acute predominantly delusional psychotic disorders (Table 2).
Likewise, emotional and confusional reactions with psychotic symptoms conform to F23.0
Acute polymorphic psychotic disorder without symptoms of schizophrenia. Although ICD-10
lacks provisions for affective disorders associated with stress factors, reactive depression and reac-
tive excitation are classified as Manic episode, Bipolar disorder, Depressive episode or
Recurrent depression.
Table 2. Scandinavian psychogenic psychoses and ICD-10 (see text for details)
Clinical types ICD-10 category
Emotional reactions F23.01 * Acute and transient psychotic disorder without schizophrenic
symptoms
F30 Manic episode
F31 Bipolar affective disorder
F32 Depressive episode
F33 Recurrent depressive disorder
F43 Reaction to severe stress and adjustment disorders
Disorders of consciousness F23.01 * Acute and transient psychotic disorder without schizophrenic
symptoms
F44 Dissociative disorders
Paranoid states F23.11 * Acute and transient psychotic disorder with schizophrenic
symptoms
F23.21* Acute schizophrenia-like psychotic disorder
F23.31* Other acute predominantly delusional disorder
*Associatied with acute stress
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62 History of Psychiatry 21(1)
Another category where emotional syndromes can be accommodated is Reaction to severe stress
and adjustment disorders, within the F4 group Neurotic, stress-related and somatoform disorders.
It comprises: Acute stress reaction reminiscent of shell shock or combat stress reaction which is
described as an immediate and self-limiting reaction (OBrien, 1998); Post-traumatic stress disorder
which is a delayed and/or protracted response to catastrophic or life-threatening situations; and
Adjustment disorders which refer to states of subjective distress and abnormal reactive patterns aris-
ing within one month of exposure to continued stressful events or life-changes.
Furthermore confusional reactions are classified under Dissociative disorders such as
Amnesia, Fugue, Stupor, Trance and possession, Ganser syndrome and Multiple person-
ality disorder. These disorders are presumed to have a psychogenic causation in terms of either
traumatic events, insoluble and intolerable problems, or disturbed relationships.
To evaluate the continuity between PP and ATPD, a study was conducted on a cohort of cases
drawn from the Danish psychiatric register (Castagnini, Bertelsen, Munk-Jrgensen and Berrios,
2007). Patients enrolled with an ICD-8 diagnosis of Other psychoses in 199293 were identified
from the electronic database and their diagnoses were compared with the ICD-10 categories they
were assigned when readmitted in 199495.
9
It was found that PP accounted for 19% of functional
psychoses in 199293, whereas ATPD decreased to 9% of those with psychotic and affective dis-
orders in 199495. F2 Schizophrenia and related disorders and F3 Affective disorders com-
prised almost three-quarters of cases previously diagnosed with PP. ATPD was the most frequently
used category, though the overlap with PP was only 20%. Recurrent depression, depressive episode
and bipolar disorder were the principal F3 categories.
Among ATPD subcategories, PP tended to conform more to acute predominantly delusional
disorder. Only a small number of cases were associated with acute stress. It is likely that stress fac-
tors were underestimated on register reports because coded as an additional diagnostic feature.
Although the approach adopted in ICD-10 makes comparisons with the intuitively-based ICD-8
diagnosis of PP difficult, these findings suggest little empirical continuity to ATPD.
Conclusions
Drawing on the view that life events may give rise to meaningful reactions, Wimmers concept of
PP embraces a number of clinical phenomena triggered by traumatic circumstances to which the
subject may be vulnerable owing to past experiences or mental predisposition. Although little can
be found in Wimmers (1916) work that was not already in the literature at that time, his arrange-
ment of the clinical material is new.
The following factors contributed to the transformation of PP:
Wimmer designated a group too composite to be accepted as a category separate from schizo-
phrenia and manic depression according to the post-Kraepelinian model of mental illness;
further modifications made through successive work of other Scandinavian authors, notably
Strmgren, Frgeman and Retterstl;
Schneider sharpened the distinction between reaction and psychosis as a brain disease
causing the relegation of PP to marginal categories in modern classifications;
the psychological mechanism of reactivity on which PP are based has been re-defined
in terms of stress vulnerability, life events, social adversities, etc.;
emotional syndromes, formerly the main group of PP, are now subsumed under affective
disorders, and confusional reactions listed either as dissociative states or organic mental
disorders.
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Castagnini 63
It is concluded that the changes in the concept of PP reflect the mutations of twentieth-century
classification of psychotic disorders. Paraphrasing Hoenig (Strmgren, 1985: 197), PP are no lon-
ger used and treasured as a national heritage in Scandinavian countries, but have almost dropped
out of circulation since the introduction of ICD-10.
Acknowledgements
I would like to thank Professor G. E. Berrios for helpful suggestions. Thanks are also due to Dr A. Bertelsen
and an anonymous referee for comments on an early draft of the paper.
Notes
1 For Strmgren (1974: 99) Wimmers monograph represented the first comprehensive survey of the
whole field. The important contributions from French and German psychiatrists (Janet, Srieux and
Capgras, Birnbaum, Bonhoffer, and Raecke) had been of a more or less casuistic nature. ... He stressed
the importance of Freuds contribution to psychiatry, and pointed out that the descriptive technique
had probably exhausted itself; more attention should be paid to the dynamics of psychopathological
mechanisms.
2 Wimmers book comprises an illustrative sample of 24 case-histories. A number of these sketch
psychogenic depressions, followed by case-vignettes with stupor, hysterical features, twilight states and
hallucinations. Others appear to suffer from either paranoid psychosis or obsessive-compulsive disorder.
There also are cases in which somatic illnesses and physiological conditions (menstruation, pregnancy,
etc.) concur to elicit abnormal reactions, rendering the psychogenic aetiology uncertain. Even less
likely to qualify as reactive psychoses are some cases which fail to exhibit any clear relationship with
precipitating factors or psychotic symptomatology (Gerevich & Ungvari, 2004; Varghese, 2004).
3 All extracts from Wimmer (1916) are taken from Schioldanns (2003) translation; italics are from the
original unless otherwise stated.
4 Schioldann (2003: 44) states that Wimmers definition of psychogenic psychoses was a natural
development of his extensive studies of the relevant French and German literature (e.g., Magnan, Legrain
and Reiss), and his own clinical investigations, especially his 1902 doctoral dissertation, Evolutive
paranoia.
5 Before the publication of Allgemeine Psychopathologie in 1913, Jaspers dealt with reaction in his
doctoral thesis, Heimweh und Verbrechen (Nostalgia and crime, 1909), and he wrote a long article of
over one hundred pages entitled Kausale und verstndliche Zusammenhnge zwischen Schicksal und
Psychose bei der Dementia praecox (Schizophrenie) (Jaspers, 1913b/1974).
6 The concept of bouffe dlirante stems from the nineteenth-century French theory of degeneration. Magnan
(1893) separated delusional disorders with acute onset and favourable prognosis from conditions with a
relatively more stable and uniform clinical patter (dlire chronique volution sistmatique), leading
eventually to mental deterioration. He stressed the role of a vulnerable constitution, while downplaying
the contribution of external events. Magnans formulation of bouffe dlirante bears striking similarities
to that put forward by Ey (1954). Abrupt onset, polymorphic symptoms and restitutio ad integrum are the
essential diagnostic features (Pichot, 1986).
7 Ungvari and Mullen (1997: 75) concur with Jauch and Carpenter (1988) that loose diagnostic practices, and
not necessarily conceptual faults, stand behind the lack of diagnostic stability of reactive psychoses, which
appear to have good reliability. similar to schizophrenia and affective psychoses (Hansen et al., 1992).
8 ATPD has been shaped, partly at least, by findings from the WHO Collaborative Study on Acute
Psychoses. This international research project, conducted in 14 centres with over 1000 cases, reported
that: (1) a large number manifested typical schizophrenic symptoms; (2) only about half were rated with
precipitating stress; (3) rapid recovery (often within some weeks) and no relapse in two-thirds of them
after 1 year (Cooper, Jablensky and Sartorius, 1990).
9 Because of only minor differences from ICD-8, ICD-9 was never used in Denmark. In 1994 ICD-10
replaced ICD-8 as a reference classification (Munk-Jrgensen et al., 1999).
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64 History of Psychiatry 21(1)
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