The Assessment of Psychosis

A Reference Book and Rating Scales for Research and Practice

Flavie Waters, Massoud Stephane, Flavie Waters, Massoud Stephane

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781134628766
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

This book reviews the descriptive features of psychotic symptoms in various medical conditions (psychiatric, early psychosis, general medical, neurological and dementia), non-medical settings (individuals without the need for care or at high risk for psychosis) and age groups (children and adolescents, adults, older adults). Similarly, the perspectives of many disciplines are provided (history, psychiatry, psychology, psychopathology, neurology, phenomenological philosophy) so that readers may become familiar with different approaches that are used to define, evaluate and categorize psychosis, at times independently of clinical diagnosis. This book is a resource book for those requiring an understanding of clinical and conceptual issues associated with psychosis, with chapters written by academics and clinicians who are leaders in their respective fields. The book also provides a guide regarding the methods of assessment for psychosis and its symptoms, with 120 rating scales, which are described and evaluated. The Assessment of Psychosis will be particularly useful to the clinical and research community, but also to readers interested in individual differences and human psychopathology.

Part I
What Is Psychosis?

1
History of Concepts about Psychosis

What Was It, What Is It?

Simon McCarthy Jones

Psychosis: A Short History

The contemporary definition of psychosis, given in the International Classification of Diseases (ICD-10; World Health Organization [WHO], 1994) as “the presence of hallucinations, delusions, or a limited number of severe abnormalities of behaviour, such as gross excitement and overactivity, marked psychomotor retardation, and catatonic behaviour” (p. 10), is one only recently arrived at. For the majority of the approximately 170 years of its existence in medical discourse, psychosis referred to a much wider class of experiences. Indeed, the root of the word, which combines the noun “psyche” (meaning spirit/soul/mind) with the suffix “-osis,” which associates its preceding noun with a pathological condition (Sommer, 2011), contains no indication it is likely to refer to the specific experiences we today associate it with. Furthermore, the original word psykhosis, as used in Ancient Greece, had no connotation of mental disorder, instead meaning animating, or giving soul or life to.

The term was originally introduced in part to replace words such as madness, insanity and lunacy (Davidson, 1954) as an “inoffensive synonym for insanity” (Sommer, 2011, p. 164), first appearing in a medical context in mid-19th century Germany. The term neurosis had been introduced in the second half of the 18th century by the Scottish physician William Cullen (1710–1790) as a term to cover “all diseases of the nervous system not accompanied by fever” (Cullen, as cited in Sommer, 2011, p. 162). Against this backdrop, psychosis was introduced to specifically refer to diseases of the brain and that resulted in mental disorder. The first use of the term appears to be in 1841 in Karl Friedrich Canstatt’s (1807–1850) Handbuch der Medicinischen, where it was used synonymously with the term psychic neurosis to describe a psychic manifestation of a disease of the brain (Bürgy, 2008). However, the person most often credited with introducing the term is the Austrian physician Baron Ernst Von Feuchtersleben (1806–1849). Feuchtersleben employed it in 1845 as a term to denote serious mental disorder (covering the four traditional categories of melancholia, mania, dementia and idiocy) and was keen to try and stress the interplay of the body and mind in creating psychosis (Beer, 1995, 1996a). At the time Feuchtersleben was faced by two extreme positions. People like Wilheim Griesinger (1817–1868) argued that “mental illnesses are diseases of the brain” (Griesinger, as cited in Beer, 1996a, p. 276), whereas others like Johann Heinroth (1773–1843), referred to as mentalists, argued that mental disorders were caused by psychological factors such as an excess of passion, or sin (Beer, 1996a). In contrast, Feuchtersleben queried if mental disorders were always due only to disorders of the brain (Beer, 1996a) and viewed the etiology of psychoses as lying in both a physical weakness of the brain and in a mental vulnerability (Bürgy, 2008). As such he conceptualized psychoses as having their roots in a “psychophysical reciprocal relation” which was “diseased in several directions” (Feuchtersleben, as cited in Beer, 1996a, p. 275).

Soon, others such as Carl Friedrich Flemming (1799–1880) were also employing the term psychosis. Flemming wrote the first textbook specifically on the psychoses (The Pathology and Treatment of the Psychoses), where he used the term psychoses to simply refer to mental disorders in general (Beer, 1996a). Psychosis was conceptualized by Flemming as being a psychological aspect of a neurosis (i.e., a physical disorder), and hence he also used the alternative term, psychoneurosis (Beer, 1996a). Flemming argued that “The brain is not merely the source of activity [physical and mental] but is the organic foundation of all expressions of the action of the soul” (Flemming, as cited in Beer, 1996a, p. 275). Despite their close link to neurological disorder, the introduction of the term psychoses meant mental pathology became increasingly viewed as a discrete entity (Bürgy, 2008).

Psychosis later came to be subdivided in different ways, including through organic-functional and exogenous-endogenous distinctions. Carl Fuerstner (1848–1906) introduced the term ‘functional psychosis’ because he did not view the psychoses as exclusively of organic aetiology (Beer, 1996b). After Fuerstner, Alois Alzheimer used the term ‘real psychoses’ as a synonym for organic psychosis, defining psychoses as “diseases of the cerebral cortex” (Beer, 1996b). Yet, there were those such as Franz Nissl (1860–1919) who thought the organic-functional distinction was worthless as, in his view, “In all psychoses of whatever type there are always positive cortical findings” (Nissl, as cited in Beer, 1996b, p. 240). Yet the term functional did not necessarily mean that there were no changes to the brain, rather that the mentals functions (will, thought, emotion) were altered in the absence of any detectable brain pathology (Beer, 1996b). Indeed, most late-nineteenth-century psychiatrists used the term functional to describe conditions which had no obvious anatomical changes, but were nevertheless thought to have molecular disturbances (Beer, 1996b). It was effectively due to the influence of Freud (1856–1939) that functional came to mean ‘nonorganic’ (Beer, 1996b).

In the 1890s the neurologist Paul Julius Moebius (author of such works as On the Physiological Weakmindedness of Women—clearly absurd—and On the Hopelessness of Psychology—let’s not rush to judgment on this one) became frustrated with the functional-organic dichotomy (Lewis, 1971). He observed it was “now customary to distinguish between organic and functional nervous disorders, in the sense that in the former changes in the affected tissue are visible after death, but not in the latter. This differentiation is useless, because it is to a large extent dependent on the methods of investigation: the pathological findings are always being added to by advances in histology” (Moebius, 1893, as cited in Lewis, 1971, p.191). Moebius went on to introduce a new subdivision based on the aetiology of a mental disorder, which he termed “classification by causes” (Lewis, 1971). This was the distinction between exogenous and endogenous disorders. Moebius argued that exogenous diseases were those which there was a main cause (necessary for the disorder to arise) which impinged on the individual from without, e.g., alcohol, lead, toxins, etc. (Beer, 1996c). In contrast, endogenous diseases were those in which there could be a range of smaller secondary subsidiary causes which meant, in Moebius’s reasoning, that “the chief [causal] factor must be in the individual himself, it must be a predisposition” (Lewis, 1971, p.191) or a “congenital debility” (Moebius, as cited in Beer, 1996c, p. 8). However, Moebius was vague in his definition of exogenous, and what exactly was meant by being “engendered from without” (Beer, 1995, p. 286). Karl Wernicke’s (1848–1905) pupil, Karl Bonhoeffer (1868–1948) applied these terms to psychosis, coining the terms endogenous and exogenous psychosis (Beer, 1996a). He conceptualized endogenous psychosis as being caused by hereditary-degenerative factors, giving examples of manic-depressive insanity and hebephrenic and paranoid psychoses (Beer, 1996a). In contrast, exogenous psychoses were those in which a trigger event could be determined, and the model invoked to understand this was of the response of the brain to injury (Lewis, 1971). As Bonhoeffer could not find a direct mechanism linking factors such as trauma or alcohol with an ensuing mental disorder, he postulated intermediate products (formed in the body as a result of these events) that he designated as being responsible for exogenous psychoses such as delirium, Korsakoff’s syndrome, epilepsy and hallucinatory conditions (Lewis, 1971).

Emil Kraepelin (1856–1926) initially classified disorders such as manic-depressive insanity, paranoia, involutional psychosis and degeneration psychoses as endogenous psychoses but did not include dementia praecox in this category (Beer, 1996a). He argued, regarding dementia praecox, that

in consideration of the close relationship with the age of puberty, the presence of disturbances of menstruation, and the frequent appearance of the disease for the first time during pregnancy and puerperium, the further assumption is made that it is the result of auto-intoxication.

(Kraepelin, as cited in Beer, 1996c, p. 14)

However, he later came to believe dementia praecox and manic-depressive insanity were the only two endogenous psychoses, and that in these, “heredity and predisposition play a significant, if not a decisive role” (Kraepelin, as cited in Beer 1996c, p. 15). He also began to use psychosis to refer to specific conditions and not to mental disorders in general, as he had done earlier (Beer, 1996a).

Other writers made further distinctions as to what characterized psychosis, with Karl Jaspers (1883–1969) and Kurt Schneider (1887–1967) being particularly influential. Jaspers used the criterion of insight, arguing that in “psychosis there is no lasting or complete insight. Where insight persists we do not speak of psychosis but personality disorder” (Jaspers, as cited in Beer, 1996a, p. 279). Jaspers also defined psychosis in clear contrast to neurosis and personality disorders. He argued that psychoses, in contrast to neuroses,

are mental and affective illnesses… [and] are generally thought to open up a gulf between sickness and health. They spring from additional disease processes, whether these are hereditary disorders beginning at certain times of life or whether they are called into being by exogenous lesions.

(ibid.)

However, he argued that the three major psychoses (epilepsy, schizophrenia and manic depression) were functional, due to a lack of evidence at the time of organic changes associated with them (Beer 1996b). His contemporary, Schneider, preferred the term endogenous (Beer, 1996b). By 1933, Schneider’s psychiatric classification system drew a sharp line between understandable normal reactions to events and psychoses, which he only conceptualized there being two of—schizophrenia and manic depression. He argued that “one could conclude that schizophrenia is an organic-constitutional, perhaps a primary cerebral disorder… in which somatically speaking there are no transitions with normality” (Schneider, as cited in Beer, 1995, p. 319).

Systems such as Schneider’s, which stressed that psychosis was a disease and that it was quite clear who was suffering from it and who was not (Beer, 1995), became important in the grotesque social/political context of the time. Given that the Nazis were asking psychiatrists which of their patients were erbkrank (congenitally mentally ill), a group that were then to be sterilized or murdered, people with a label of endogenous psychosis (which usually meant schizophrenia or manic-depressive insanity) were one group who came to be deemed erbkrank (Beer 1995, 1996a). As one of Kraepelin’s pupils, Robert Gaupp (1870–1953), chillingly put it,“it is a great piece of good fortune (when it comes to diagnosis) that it is only a question of schizophrenia or manic-depressive insanity, that is—two hereditary diseases with the same eugenic significance” (Gaupp, as cited in Beer, 1996a, p. 279). This led to a number of psychiatrists trying to save their patients from being killed by giving them diagnoses of forms of neurosis, rather than schizophrenia (Lifton, 2000).

By 1968, the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II, American Psychiatric Association [APA], 1968) continued to distinguish between “psychoses associated with organic brain syndromes” (e.g., alcoholic psychosis, psychosis associated with intracranial infection) and “psychoses not attributed to physical conditions listed previously” (e.g., schizophrenia, manic depression), with the latter group still referred to as “functional disorders” (p. 23). It defined psychosis through stating that “patients are described as psychotic when their mental functioning is sufficiently impaired to interfere grossly with their capacity to meet the ordinary demands of life. The impairment may result from a serious distortion in their capacity to recognize reality. Hallucinations and delusions, for example, may distort their perceptions” (p. 23). By the time of DSM-III (APA, 1980), although psychoses in organic mental disorders were still classified separately from schizophrenia, the term functional was not used, and the authors were clear to stress that this did

not imply that nonorganic (‘functional’) mental disorders are somehow independent of brain processes.… Limitations in our knowledge, however, sometimes make it impossible to determine whether a given mental disorder in a given individual should be considered an organic mental disorder (because it is due to brain dysfunction of known organic etiology) or whether it should be diagnosed as other than an Organic Mental Disorder (because it is more adequately accounted for as a response to psychological or social factors… o...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• List of Contributors
• Foreword: Psychosis: The Human Experience
• Preface
• I What Is Psychosis?
• II Psychosis in Different Population Groups
• III The Assessment of Psychotic Symptoms
• Part IV Rating Scales for Psychosis and Psychotic Symptoms
• Appendix 2: Index of Acronyms and Initialisms of Rating Scales
• Appendix 3: Hallucination-Specific Rating Scales (Auditory, Visual, Olfactory, Gustatory, Somatic)
• Appendix 4: Delusion and Delusional Ideation Rating Scales
• Appendix 5: Language (Formal Thought Disorder) Rating Scales
• Appendix 6: Insight-Specific Rating Scales
• Appendix 7: Self-Disturbances, Body Perception Disturbances and Passivity Symptoms Rating Scales
• Index