We intend to refer in this entry to the concept of axial syndrome of psychosis , as developed by Bartolomé Llopis, staunch advocate of the concept of single psychosis , whose importance and presence has alternately flourished and declined throughout the historical evolution of psychiatry and psychopathology. We will continue to do the text only psychosis. selected writings, that collects several works by this author. Llopis argues that the crucial problem of psychiatry is whether psychological symptoms are produced and set in each case for a particular cause or pathogenetic represent only existing response options that can be shown by various causes. The author denies the specificity of the real physical symptoms and helped to revive the theory of psychosis only (or unit, others prefer translation). In the words of Llopis, speaking of psychosis is only wants to express that mental symptoms are the same in diverse diseases, the brain, which directly or indirectly dependent condition always those symptoms, you have the same answers to all attacks, like other organs. Moreover, among all these responses there is a continuity, a transition insensitive, so that the various psychotic symptoms represent only varying degrees of intensity of the fundamental disorder.
Commenting historical background of the thesis of the single psychosis, Esquirol says: " Madness successively and alternatively can affect all these forms: mania, mania and dementia are replaced, are complicated in the course of the same disease, same individual. " For him, mania, mania and dementia are not disease entities but only forms, ie, syndromes, and also be a transition from one to another. In this sense, can be considered to Esquirol as one of the first representatives in modern times of the thesis of the single psychosis. Speaking of the causes of insanity, said that its etiology are so numerous and varied. But considering the etiology is essential for delineation of disease entities. If madness is due to so many and varied causes, is because it is a disease entity but a syndrome. Otherwise, it would have so many follies as etiological factors. Esquirol claimed that madness, in the singular, it can be produced by many different causes and may also manifest itself in diverse ways. According to Llopis, could express the thought of Esquirol saying that psychosis is a syndrome common to many diseases and that this syndrome may adopt or pass on to various forms, and also that Madness is a basic or fundamental syndrome, divisible into syndromes subordinates. Georget defended the view that mental illness was a brain disease idiopathic with a wide variety of demonstrations, which would not, however, independent diseases. He said: " can see a series of intermediate types, ensuring that there is a seamless transition between both forms of l mint condition." Neumann says in his treatise published in 1859: "We can not believe real progress in psychiatry until the general has taken the decision to throw overboard all classifications ." Also: " There is only one kind of mental disturbance and call madness." In the opinion of this author, they do not form any mental disturbance, but only stages of one and the same pathological process. Neumann was able to recognize and highlight clearly the difference between isolated events and complex symptomatic manifestations, on the one hand, and actual pathological processes, on the other. Called "elements" to those isolated events, as opposed to the real disease, which he described as "processes." He said: "The true diagnosis has nothing to do with the naming , that is knowledge of the individual case, it is the product of abstraction, and indeed an abstraction based on analogies premature. " The idea of \u200b\u200bpsychosis only reached its peak under the influence of Griesinger, who begins his treatise published in 1861 saying that insanity is not, in itself, rather than a symptom, this symptom can not be claimed more that a brain disorder. Regarding the rankings, said: " The establishment of the various groups of mental illness can only be done from a symptomatic point of view "and" can be justified only from existence. "
According Llopis, the decline of the concept of psychosis really only seems to start work Hoffmann (1861) and Snell (1865) that break with what they see as the dogma of the exclusively secondary paranoia, describing the " monomania as a primary form of mental disorder ." Griesinger accepted a "primary paranoia" and Westphal in 1876, made his classic description of the disease, emphasizing the abnormality of considering representations and affective disorders as incidental or unimportant. Thus began a process that collapsed, at least temporarily, the notion that delusions are always secondary to mood disorders, a concept that was one of the strong pillars of the theory of psychosis only. Nevertheless, the decisive blow against the single psychosis was struck by the tremendous work of nosographic Kraepelin, on the other hand, had the predecessor to Kahlbaum . Kraepelin laid causal-symptomatic principle, whereby each cause of the disease is linked to a certain psychological symptoms. It is not, however, that each corresponds a specific disease process status box. Symptomatological differences for the various diseases are much finer, much more difficult to perceive than those between the various categories of state (melancholy, mania, stupor, delirium, paranoia ...). The differences between them are so obvious that their separation has not ever offered great obstacles. In contrast, the finding of specific physical symptoms for various disease processes is a task fraught with difficulties. You can not do directly, regardless of pathological processes, a classification of major psychiatric symptoms. According to Kraepelin, natural syndromes, ie, those who can differentiate a direct and spontaneous, are accessories for the recognition of disease entities, while small symptoms of the syndrome accessories in total in which they appear, may be critical to the diagnosis of underlying disease. Also admits that the difference in disease processes is often most clearly highlighted in the course of the disease. He says: " precisely why the consideration of the progress and completion of the mentally ill seems to me extremely important for delimitation. " With Kraepelin, reaches its climax psychiatric systematics based on the specificity of psychiatric symptoms and collapses completely unique concept of psychosis, and seriously undermined by the theft of your emotional base to the paranoia.
Subsequently, the first-symptomatic etiology Kraepelin was subjected to multiple attacks. As pointed out by Llopis, after the collapse of the theory of psychosis only appeared four ideological currents that converged to the resurrection of this thesis: the recognition of the specificity of psychological symptoms (Hoche, Bonhoeffer, Specht, Hartmann, Bumke, etc. ), the application of evolutionary perspectives to the study of nervous system disorders (Jackson, Monakow, Janet, Ey, etc.) overcoming the consideration atomistic psychology unit of psychic life (psychology of the whole , psychology of form, etc..) and also overcome the old doctrine brain locations of mental functions and views that emphasize especially the importance of joint activity throughout the brain (Flourens, Lahsley, Goldstein, etc..). Common to all these trends is a tendency synthetic, unifying, which openly opposes the momentum analyzer, specific and distinctive characteristic of all attempts at classification. After this overview, it is clear that since the beginning of scientific psychiatry have taken two approaches to the problem of mental disorders: a synthetic, meeting the symptoms in the great unity of the so-called single psychosis, which represents the same response but with varying degrees intensity, the more varied attacks, another analytical, which breaks down and distributes multiple psychotic symptoms specifically determined by the various pathogenic causes. Both tendencies have fought, sometimes with burning, but as stated Jaspers, " instead of fighting, could be complemented ." Llopis argues that there really is no argument between the two compatible. Nor the necessary classification of mental illness can destroy the unity of psychic disorders flowing nor the recognition of this unity means no obstacles to psychiatric nosology. Mental diseases called leads to impaired mental activity, which may have varying degrees of intensity. When all these conditions is what has been called "one psychosis", and Llopis, to avoid confusion, has proposed to call " axial syndrome common to all psychoses ." The varying degrees of this syndrome are not pathognomonic axial any disease, but could support a possible causal disease, especially if we consider also its temporal variations, ie the course of psychosis.
Llopis Turning to what he calls his own concepts about psychosis only, it is necessary to clarify what is meant by syndromes of the state and content of consciousness. considers Awareness as the ability to know and knowing is always distinctions or differentiations. Knowing is one thing to distinguish, to separate what is not herself. There is no mental act than an act of knowledge. Consciousness and psychic activity are therefore synonymous concepts. Call state of consciousness to the degree of clarity or lucidity, which is expressed by a greater or lesser capacity to know. Content consciousness is all that is known (noticed sense, perceived, apprehended) by consciousness. Contents pathological consciousness can not be more than those that reflect the abnormal situation of the organism itself, that is, in general, any content provided not by the external senses, but by the internal sensitivity for the cenesthesia. In contrast, pathological states of consciousness pertain to both external and internal stimuli. The pathological contents of consciousness can not be regarded indeed as psychological disorders. Their awareness is limited to take cognizance of a disorder of the body.
However, the fact that the syndromes of the content of consciousness are not mental disorders per se, does not mean lack of extraordinary importance in the shaping of the psychotic disorders, ie what Llopis called syndromes mental picture. The mentally ill do not express an immediate and pure content, ie, feelings, plastic materials offered to the activity of conscience, nor the same activity, what they say are the works that those materials build their awareness. In such works, or psychotic symptoms are integrated, for both content disorders such as mental activity or state of consciousness. The fact that these works are also still qualify as content ( psychotic content) should not lead to confusion. The psychotic episodes are, in effect, rather than psychological content, but psychic contents which has left its stamp on disorders of consciousness. To be designated as containing psychotic need to reveal the existence of a disorder of the state of consciousness. Table psychological syndromes are psychotic symptoms such as is an empirical observation. Now if we consider the essence of any mental disturbance as a projection experiences the outside world caused by internal stimuli, we can formulate the following questions: What is the degree or intensity of the projection? What is projected? Thus Table psychotic breaks in its two constituent factors: the syndrome of the state and the syndrome of the contents of consciousness. The transformation of the contents or primary disease (syndromes of the content of consciousness) in psychotic or secondary content (Table psychological syndromes) is performed, then, under the action of the true and only conditions of psychic activity, which are the syndromes call status consciousness. This action metamorfótica mental disorder on the contents of consciousness seems to be regulated by two fundamental principles: principle of "like" or metaphor and introversion principle.
The principle of "like" or metaphor explains that the somatic sensations produced by stimuli internal, normal or pathological, can not be analyzed and described if not comparing with sensory impressions caused by external causes. Pellagra patients, for example, describe their pain and numbness: "I ran like snakes ... as if a dog bit me ... as if it were on fire ...". They are images, metaphors of the external world with which patients express their inner impressions miss. The same applies to those internal anomalies, more diffuse, which we perceive as feelings or emotions: "I notice a sense of unease, as if danger threatens me ...". The feeling is invariably adequate image of the outside world to the affective. Kinesthetic impressions are always linked to representations of the external world. These representations or images arise automatically, aroused by the inner impressions, and serve the normal subjects to describe metaphorically, through the phrase "as if" the particular quality of those impressions. But these individuals do not confuse the feeling with the image, the internal with the external reality with the metaphor.
Moreover, the principle of introversion is explained from the point of view that any disruption psychic is a reduced ability to learn in a decreased level of consciousness. As this decline is occurring, patients are losing touch with the outside world and immersing himself in his own inner world. Gradually abandon the objective world, common to all, and are enclosed in increasingly subjective world, individual. As to the introversion simultaneously be losing the ability to know, to differentiate, prove that parallel to the loss of contact with the outside world, they will be breaking down the boundaries between the sensations and representations, internal and external, the subjective and the objective, reality and metaphor. Patients lose awareness of the metaphorical significance as before, in the experience of "as if" they lived properly as a metaphor, now living as a reality.
Doubt is the great achievement of man because it involves self-knowledge, ie differentiation between self and world, or between an inner and outer world. When human consciousness declines with fatigue, sleep, or illness in psychosis, man loses the privilege of the doubt and sinks an unshakable security. This security is all the more regrettable that due to the Introversion principle, the content offered to consciousness are becoming less objective picture of the outside world and more and more images created by your own imagination under the influence of internal stimuli. We tend to project into the outside world, to live as if they were objective realities, all kinds of subjective fantasies. Llopis Cree only different degrees of such a projection (which does not express, in short, more than a car and alopsíquica disorientation, an inability to discriminate between the given objectively in the outside world and given only in the self) can explain purely quantitative transitions between the different syndromes of the state of consciousness, despite its apparent qualitative differences.
From their point of view, neurosis can not be considered rather than syndromes content consciousness. It is not in them of true changes in mental activity, but affective states, among which is a particularly prominent anxiety. These affective states are only the expression subjective somatic disorders and the fact that the fundamental somatic disorder lacks a clear objective expression does not mean it does not exist. The fact that arouse affective disorders, depending on the experience of "as if" representations or memories (biographical anecdotes) easily leads to the error of confusing cause with consequence. As for affective syndromes, syndromes are considered content of consciousness that do not involve any disturbance of mental activity. However, longtime supporters of psychosis only consider melancholia and mania as phases of this psychosis. This apparent contradiction is explained by the process of introversion of consciousness. At the beginning of this process, the consciousness becomes less intellectual and more emotional, affective content then dominate over all other possible contents of consciousness. The more advanced the process more intense psychotic introversion and acquire predominance emotional content, but as simultaneously launches the mechanism of projection, the affections are clad increasingly apparent objectivity, it covers an increasingly external events alleged plot, so that these alleged events (paranoid ideas, hallucinations ...) acquire hegemony in the box psychotic while those with truly primary and fundamental, reduced almost to vanish, apparently, to mere reactive consequences. Thus, although the affective syndromes may persist through all stages of psychosis may manifest itself only with evidence in the initial stage. It should be stressed that melancholia and mania are psychic contents and, therefore, are not genuine stages of psychosis, much less subsequent stages. What happens is that in the first stage of the psychosis which reveals more clearly the emotional situation, regardless of the patient, may occur it is neither sad nor happy, but indifferent, what should be possible to poverty or lack of kinesthetic stimuli.
Referring to the paranoid syndromes, and within the normal psychic is a tendency to project one's own feelings in the outside world, ie to distort the true picture of the world in favor of their own emotional situation. For this projection becomes more severe disease requires a decrease in the level of consciousness. In the most serious obsessions, the projection still faced with an emotional understanding of reality, with a critical consciousness, which can reject objectively unreasonable or absurd occurrences or representations awakened by affection. However, paranoid ideas, the projection is stronger and no longer question the external justification of such occurrences, which are experienced as if they were the exact meaning of external reality. Typical of the paranoid ideas is that the projection of subjective state, without actually modifying the sensory image of the external world, gives it a peculiar significance in relation to self. Consciousness is lost chance and all people live as if you were encouraged by certain designs, which can be favorable or hostile, as the subject's emotional state. Affection is the force that gives direction and paranoid ideas, resulting in a factor essential constituent of any idea of \u200b\u200bthis nature. But affection is not enough, with addition of a decreased level of consciousness that the experiences aroused by the affection is projected onto the external world, ie to live as if they are justified not by the inner reality, but by external reality. The old debate about the origin primarily emotional or intellectual paranoia would be ill-conceived, as both disorders (the content and the state of consciousness) are also indispensable for the genesis of paranoia.
About hallucinatory syndromes, Llopis insists that all psychopathological phenomena, even the most disparate, can be explained by only quantitative variations of a single critical condition. Thus attributed the passage of paranoid ideas to hallucinations, ie, thought disorders to disturbances of perception, for the simple progressive decrease in the ability to know. The thoughts and perceptions are yields of a single function, which is the ability to learn. Perceptions are simple knowledge of the physical presence of things while thoughts are knowledge of the meaning or significance of such transcendent things. Thus, disorders of thought and perception are not qualitatively different, but only modes of expression of different degrees of intensity of a single critical condition.
Moreover, the author argues also the analogy between psychosis and sleep, noting that the process of introversion, loss of contact with the outside world, to plunge into the inner, is a phenomenon common to the madness and sleep. Awareness or ability to learn can not be altered more than one sense of the decline in their yields. It does not matter that this alteration is caused by abnormal pathological factors for the normal action of physiological fatigue. The axial syndrome common to all psychoses or series of mental states constituting the single psychosis, there is therefore nothing but the same sequence of states of consciousness that we in the transition from wakefulness to sleep.
box because everything can be decomposed into a psychotic syndrome and content-based state of consciousness , we must consider what the relationship between each of these two kinds of syndromes and diseases that produce them. Syndromes of the content of consciousness are merely subjective manifestations of disease, depending on both the soma sensitive sites that have been attacked by the disease. Refers here to involvement of different receptors or sensory systems, both in the brain itself as anywhere in the body. In contrast, syndromes of the state of consciousness correspond to different degrees of reduced ability to learn, and this ability depends on the joint activity of the brain. Their cause must be sought in those pathogenic insults affecting the unitary and global function of the brain. Syndromes of the state of consciousness correspond to different degrees of what Jackson called "uniform solution nervous system, in which the whole system is under the same corrupting influences, although the most recent ones under higher yields, "yield" in the first place and there is a progressive and homogeneous regression to lower functional levels. The declines at progressively lower levels of functional activity of the nervous system does not reflect a different location within it, but just a different intensity, a different degree of "harmfulness" of pathogenic noxa. In short, the syndromes of the content of consciousness depends on the particular affinity for locating the pathogenic noxa with respect to the various parts of the body, while the syndromes of the state of consciousness depend on the degree of psychological harm that noxa. That is different origins, including syndromes of the state of consciousness there are only quantitative differences that allow their management in a continuous series (the single psychosis or axial syndrome common to all psychoses), while in the syndromes of the content of consciousness are qualitative differences as they may affect different sensory qualities. Within the general specificity of these syndromes, the contents of consciousness have greater value in the differential diagnosis. Both syndromes show, at least within certain limits, certain trends causal disease processes, and such trends is much more affinity localizatoria constant and characteristic that the harmfulness psychic. The diagnostic value increases dramatically if you take into account the combination of both syndromes in which we have called mental picture syndrome. In such symptoms are units of a higher order, which keep a dual relationship with the organic process grounds, will serve much better to find out. Units of a still higher order syndromes that are psychic box psychotic courses. These express the sequence, ie the sum over time of those pictures. Translate not only the harm and the location of the process but also their temporal variations.
However, only in very exceptional cases we can make a diagnosis with absolute certainty, taking into account only the psychic manifestations disease. In many diseases, especially those that underlie the so-called endogenous psychoses, our inability to discover somatic targets only forces us to diagnose the psychological symptoms. It is certain that we are satisfied many times misdiagnosed. We stop, Finally, in discussions carried out by Llopis about schizophrenia. Believes that under that label is not showing more than a syndrome, or rather, a series of psychopathological syndromes without somatic basis determined. On such grounds as may be determined somatic probably dissolve the nosological concept of schizophrenia in a multitude of heterogeneous. Do not forget that these syndromes are essentially nonspecific and can occur not only endogenous but also exogenous diseases, diseases of somatic bases inaccessible to our means of investigation and in other well-known and well diagnosable. The diagnosis of schizophrenia is always recognition of our inability to discover the fundamental organic disease, it's like hide our ignorance under a label. Many times we are not individually responsible for such failure, because this depends on the state of our science, but many times yes, because the diagnosis is made without depleting the patient's mental status examination, because it gives a specific meaning to the mental symptoms, because syndrome is attributed to a psychic the value of a disease entity.
