, wanted to title the entry On the nonexistence of hysterical psychosis but even to us, it seemed too pretentious paraphrase Jean Pierre Falret and In the absence of monomania. Falret was the undertaker of the paradigm of mental alinación and, in turn, lighter mental illness which, structural vagaries aside, we still dominates (and the choice of this verb, like any Lacanian would tell you it is no accident) . Finally, in any case and as I said Ende, that's another story, and must be told another time. We chose also not without some pretension, put in the title the issue of a construction diagnosis and our, humble attempt deconstruction of it.
Focusing on the topic at hand, hysterical psychosis has led and is still a challenge to nosological level intractable. Has been defined as an apparent psychosis is not so, in relation to neurotic personality structures, in particular, hysterical. It is common, and we use it extensively in the past, the analogy between epilepsy and converting pseudoconvulsivas crisis on the one hand, and acute psychosis and psychotic hysterical, on the other. We said a few years ago, with the audacity that gives not know much but believe that they know (not like now, every time we have more than this how little we really know, and not just referring to us) that, in the same way pseudoconvulsiva converting a crisis is a simulation unconscious of epilepsy, hysterical psychosis would be a simulation unconscious of psychosis. Even leaving aside the issue of conscious non finalists simulations, such as Munchausen, which would be subject to separate consideration, this analogy is epistemologically tricky.
And it is because we have means to know when we are so accurate with epilepsy (EEG, for example), but we have no way of knowing in an equally accurate when we have a psychosis. That is, we have the clinic, of course, but this is subjective and ever comment, and therefore can not distinguish a clinic really other psychotic apparently psychotic. Or, at least can not distinguish between reality and appearance of an objective and doubt among observers. And hence the peculiar diagnostic concordance between different professionals often have diagnoses such as psychotic hysteria or, more modern (or, in other words, a much less interesting) dissociative disorder.
time ago, wrote an article in the Journal of the NEA, which dealt with the issue of diagnosis difference between acute psychosis and hysterical psychosis, which can read entire here. We will collect some fragments of the literature review we did on that occasion, to conclude then with our current view of the subject (in case you had not you noticed, this entry itself is long).
The Treaty of Psychiatry of Eugen Bleuler (German edition 1960 of Manfred Bleuler ) takes a particular stance to the issue: part cross a diagnosis of schizophrenia based on the primary symptoms of lassitude associative, affective disorder, ambivalence and autism. This approach allows the inclusion cross within the group of schizophrenias of acute psychotic episodes with complete healing, ie what would now consider acute psychotic disorders, according to the ICD-10. This extension of the concept of schizophrenia in comparison with the narrowest of Kraepelin , which required the presence of a longitudinal decline implies an improvement in the forecast, but partially lost the ability to differentiate between acute psychosis and schizophrenia.
Moreover, in the chapter on hysteria, Bleuler speaks of so-called hysterical twilight states in which appears disoriented, delusional ideas seemingly mystical theme, paranoid, sexual or otherwise, acute confusional or hallucinatory states, with a predominance of visual hallucinations. This may occur with intense anxiety or not. Other related syndromes which includes this author would be the childishness hysterical states of stupor or state of vagrancy. In describing these tables is illustrated with identity today called dissociative disorders according to the use classifications, fleeing the term "hysteria" as if ignoring it disappeared. There also seems difficult to see these hysterical twilight states patients who are diagnosed with psychosis often hysterical.
We especially interesting comment which Bleuler on the difficulty of differential diagnosis between schizophrenia (where as we saw, this author also brings to the tables with acute psychotic symptoms of schizophrenia) and certain type hysterical phenomena: " acute psychogenic states, for example, hysterical twilight states can be defined almost always to the schizophrenia due to be easier to explain psychologically, its an emotional attachment to a particular elemental or tendency demonstration of their dependence on the spectators or participants. See also arise acute psychosis, consecutive to trauma [...], who adopt a schizophrenic symptoms at all, and yet heal quickly with psychotherapy ("schizophrenic reactions"). We do not know clearly whether in such cases it is a purely psychogenic disorder, which only maintains an outward resemblance to schizophrenia, or whether it is a psychological reaction to a latent schizophrenia or schizophrenia triggered psychologically. Only there will be agreement on all these problems when they have clarified the essence of schizophrenia and the extent to which psychological understanding is likely . "
Vallejo-Nagera , in his famous manual Introduction to Psychiatry (Edition 1971) does not directly address the issue. Describe the hysteria and, within it mentions the psychogenic twilight states, which differs from all the dissociative disorders, which includes amnesia, leakage and multiple personality, not making a specific reference to the pictures that we consider in clinical practice as hysterical psychosis. Concerning psychotic disorders, mentioned various types of organic cause acute psychosis, including calls exogenous psychosis (delirium, twilight state exogenous), but within of the syndromes called endogenous only takes into account the schizophrenic psychosis and paranoia with related paintings, not to mention what we consider acute psychotic disorders.
Henri Ey, where Treaty of Psychiatry (eighth edition, 1978) ; divides characteristically mental pathology in acute and chronic. Book a full chapter to address the issue of what he calls "psychosis acute delirium, "considering that are characterized by the sudden emergence of a transient delirium usually polymorphic in their tracks and demonstrations. Hey points out the difficulty in framing nosologically these pictures, even having been denied by some authors as we saw previously with Bleuler, who assimilated into the concept of schizophrenia. Bumke, for their part, framed in atypical manic crisis in psychoses confusooníricas Régis. Henri Ey gives a detailed historical review of the concept: Magnan described these psychosis with delusions bouffe name of the degenerate, indicating that the "explosion" occurs on a delusional certain bias (the notion of degeneration). These forms were described as acute delirium acute paranoia (Westphal), episodic twilight states (Kleist) or oniroides (Mayer-Gross), paranoid reaction, delusion of persecution cured, etc.. Largely correspond to the descriptions of primary delusional experience Jaspers, the severe conditions of mental automatism Clérambault and the concept of acute schizophrenia in different authors.
Ey says differently depending on the "mechanism" prevalent delirium: imaginative, interpretive and hallucinatory. As the forecast says that while it may be isolated incidents, always weigh the threat of a recurrence and a risk of progression to schizophrenia or chronic delusion. It is striking that among the factors of good prognosis include the suddenness of delirium, its wealth of imagination, consciousness disorders, neurotic background (mostly hysterical), dramatizing theatrical experience delusional or shortness of crisis. Most of these factors remind us of the typical characteristics of psychoses hysterical, suggesting the difficulty in clearly separating the nosologically of acute psychotic symptoms of those, confusion seems to persist to this day.
As hysterical psychosis itself, Hey do not talk about them directly. Referred to within the so-called acute neurotic reactions or emotional psychoneurosis "to crises and histeroansiosas confusoansiosas, which he describes as acute crisis triggered panic before a shock emotional, accompanied by varying degrees of stupor, agitation, or mental confusion, which may be what many authors call, as we have seen previously, psychogenic twilight states and could be roughly equivalent to the aforementioned hysterical psychosis. The difficulty increases when Ey designated as one of the possible complications of these states of distress the evolution of a psychosis, including schizophrenia-like sometimes. Also in his chapter on hysteria mentions the hysterical twilight states and second states, as states of trance, with impairment of consciousness vigil starting and ending abrupt and sometimes with the presence of dream-like visual hallucinations. Is clear overlap between these states and described hysteria in acute neurotic reactions.
Kaplan and Sadock in the 1989 edition of his Textbook of psychiatry take a different position to that of Ey. Little attention is given to acute delusional psychoses, except in a chapter devoted to "rare psychiatric disorders, atypical psychoses and brief reactive psychosis" which presents a series of pictures with few points in common, Ganser syndrome, folie à deux, the disease of Gilles de la Tourette, Cotard syndrome, Munchausen syndrome, the Amok, the Koro, etc. Most striking is the description of the brief reactive psychosis and psychotic symptoms preceded by stressful life events, acute and florid symptoms and good prognosis. The patient has lost touch with reality and has hallucinations, delusions, formal thought disorders and aberrant behaviors can be dangerous to himself or others. Kaplan says that this disorder has been called before acute schizophrenic disorder, schizoaffective disorder, catatonic and paranoid schizophrenia, psychotic affective disorder or atypical psychosis. And, absolutely clear, equals the disorder with hysterical psychosis, that is, for Kaplan the brief reactive psychotic symptoms are the same entity as hysterical psychosis, rejecting the concept of acute delirious psychosis in the sense and not to mention Ey own psychogenic twilight states of hysteria (yes says other dissociative disorders such as amnesia, fugues, multiple personality, etc..). Recommended for these disorders, symptomatic treatment with antipsychotics and follow up with psychotherapy, noting that its duration is usually less than a week.
The WHO published in 1992 tenth revision of the International Classification of Diseases (ICD-10 ) , referring to the mental and behavioral disorders. Is this the nosological system used at present in our environment and presents a position on the problem that we studied clearly different from that seen in Kaplan. The ICD-10 recognizes the existence of acute and transient psychotic disorders such as pictures of its own. These tables can appear or not as stress-related and are classified as acute polymorphic psychotic disorder with or without symptoms of schizophrenia (which include delusions and the controversial bouffe cycloid psychoses), acute psychotic disorder or schizophrenia-like (including acute schizophrenias schizophreniform disorder), and residual categories. One of these is the "other acute psychotic disorder with delusions dominance," where they can accommodate paranoid reactions and psychogenic paranoid psychosis, the latter table whose name appears near the contentious and difficult to locate hysterical psychosis. Other categories waste is "acute and transient psychotic disorder not specified" in which, without explanation added, it includes brief reactive psychosis, table, as we saw, the 1989 edition of Kaplan assimilated hysterical psychosis.
Moreover, the issue is again complicated (even more) if you look at the classification does the ICD-10 dissociative disorders. In the introduction to this group and states that are included hysterical psychoses in it, but then they are not mentioned by that name in any of the paragraphs, but in the "other dissociative disorders (conversion) specified" includes Psychogenic confusion Psychogenic twilight state and, pictures that seem to have over a great similarity literature, if not identity, with hysterical psychosis. Therefore, although the ICD is clearly in place these in dissociative disorders rather than psychotic, lets mention in the last of conditions, at least, an important reminder of hysterical psychosis.
For its part, the DSM-IV-TR (2000) of the APA describes brief psychotic disorder, requiring less than one month (between one and six months would be diagnosed schizophreniform disorder), which can occur with or without triggering serious. If any such trigger, the table is considered identical with brief reactive psychosis in DSM-III-R, which was defined by Kaplan box (1989) as synonymous with hysterical psychosis. The differential diagnosis of the DSM-IV-TR provides for brief psychotic disorder not mention dissociative disorders. The DSM category for these dissociative disorders is similar to that described in ICD-10, except that leaves excluding conversion disorder, but there is no explicit reference to the hysterical psychosis. In the category of the DSM for conversion disorder (within the somatoform disorders) comments on the possibility that hallucinations occur in these disorders, but without the presence of other psychotic symptoms and keeping intact the sense of reality. Again appears, at least in part, hysterical psychosis, not being clearly not classified DSM-IV-TR, or at least not as a unitary framework defined.
Ruiloba Vallejo, in the fifth edition of its manual Introduction to Psychopathology and Psychiatry (2002) does not devote a chapter to the acute psychotic disorders, although mentioned in the existence of schizophrenia schizophreniform disorder and brief reactive psychosis, but without stopping to describe them. Moreover, in the chapter describes the state of hysteria seconds, Ey considered similar (but not identical) to psychogenic twilight states as equivalent to dissociative identity disorder or multiple personality. Then also said the existence of what he calls acute dissociative states, which includes the Ganser syndrome, twilight state and amnesia and hallucinatory states, but describing only the first. One could assume that would be hysterical psychosis framed here, but then again you lose your drive, put forward by other authors, with brief reactive psychosis.
The Synopsis of Psychiatry of Kaplan-Sadock, 2003 strictly follows the criteria of DSM-IV-TR, but acknowledges that brief psychotic disorder contained in this classification includes patients who were previously diagnosed with reactive psychosis, hysterical, and psychogenic stress. It also considers the condition as similar to what the French call psychiatry bouffée delusional. Moreover, in the section of dissociative disorders is not any mention of hysterical psychosis or psychogenic twilight states, although the Ganser syndrome. Nor is there any reference in the chapter on conversion disorder.
After this review of some of the authors and major classification systems in psychiatry in recent decades, The conclusion we draw is that there are major disputes are far from being clarified. The concept of hysterical psychosis is very problematic and not clearly defined, placing both in acute psychotic disorders such as dissociative disorders, and sometimes simultaneously in one section to another. We have seen that determine nature and classification of acute psychotic disorders is not easy, and there is very different and sometimes conflicting according to the author to address the issue. Nor is there a unified idea about the explanation and scope of the dissociative disorders. Probably influences the difficulty of nosological framework that the concept we call hysterical psychosis varies greatly from one author to another and rely heavily on the subjectivity of each clinician. It is possible to hypothesize the existence of a continuum between psychotic pole (which would be almost indistinguishable from acute psychosis) and dissociation, as is often difficult to locate other disorders at qualifier, although this hypothesis remains a mental construct, like many others, without clear empirical support.
Not to comment here, since it would deviate from the topic, how today are forgotten these acute psychosis designed to cure even before the neuroleptic era, for the benefit of conceptualizing psychopathology all this first episode of schizophrenia, with the stigmatic that entails, as well as chronicity and prognosis negative. And with such a diagnosis of first episode (and we know that language is not innocent, we and all professionals, family and patient, waiting for the arrival of a second), the possible cure which often ended classical acute psychoses easily attributed to concomitant medication, with which it will continue to manage for a considerable time, who knows if undefined, you may not need (but at great cost and with side effects that we know).
And as hysterical psychosis, what end? We have no idea whether such a construct actually exists. Or, to avoid falling into essentialism of any fur, we have no idea if there really are patients with hysterical psychosis are different from those suffering from acute psychosis. Perhaps in some cases wrong simulators (conscious) with patients. Or certain (mis) handling of negative countertransference ultimately lead to diagnoses that continue to be derogatory, as anyone who runs with the adjective hysterical.
Moreover, beyond notions of truth and falsehood , and focusing on issues of utility and futility , can we really say that this differential diagnosis is of any use? The prognosis (if we call first to what should be called acute ) is similar, since both tend to resolution pictures and, sometimes, to relapse. Treatment is also similar, as antipsychotics tend to be used in both cases, reducing anxiety, insomnia, calm, perhaps the most striking symptoms reduce delusional or hallucinatory ... Y el abordaje psicoterapéutico debe ser de contención y apoyo en ambos. Por otra parte, el diagnóstico de psicosis histérica conlleva, para qué engañarnos, una carga peyorativa importante, siendo muchas veces más un juicio moral que clínico. Algo del orden de “ se lo está haciendo… no es un verdadero paciente… hay que cortar cualquier beneficio externo para que reaccione… ” y otras lindezas que, en ocasiones, nos llevan a que el paciente no sea tan bien tratado como debería (hoy sí que estamos sutiles, quién lo iba a decir). Todo ello, tal vez, fruto de lecciones de psicoanálisis mal explicadas y peor entendidas.
Our proposal is, therefore, that since we do not know for sure whether it makes sense epistemologically a diagnosis of hysterical psychosis since in any case, we believe that is not practical, it is best not to make such a diagnosis. We preferred syndromic diagnosis of acute psychosis and approached as such. And once diagnosed with acute psychosis, let the order numbers for mathematicians and ill omens for the liars, and we hope to confirm that the prognosis is poor and chronic psychosis, before announcing to the four winds. Lest the patient after full recovery, as saying the classics, wants to continue his life wherever psychosis is interrupted and, instead of helping, we're going to hurt to misdiagnosis or unnecessary treatment.
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