Degenerative Psychoses

DEGENERATIVE PSYCHOSES, a concept that grew out of Morel's doctrine of degeneration and was most fully developed by French psychiatrists, especially Magnan. According to the latter's views, a predisposition to mental illness, which may be hereditary or acquired, stems either from simple fragility of the psyche or from degeneration. Individuals with a simple predisposition possess a normal, though easily disturbed, brain mechanism; those who are degenerating, however, have an abnormal brain structure at all times—a circumstance by which they are distinguished from birth by persistent anomalies in all areas of psychic life. Under no circumstances could these patients feel, think, and act like subjects with a normal brain; they are different beings, the equilibrium between all their brain functions is disturbed and cannot be restored. Even in cases where they cannot be called mentally ill at all, the lack of equilibrium sharply distinguishes them from other people. Their brain is generally a place of least resistance, due to which even purely physiological moments (puberty, menstruation, pregnancy, childbirth, menopause) become causes of brain disorder in them, and febrile diseases are always accompanied by delirium. True, prolonged mental illnesses also develop easily in them. Since the substrate of psychic activity in such people is poorly organized, cases of insanity with an unfavorable outcome—without lucid intervals, but only with remissions—are frequent. In German psychiatric science, the concept of degenerative psychoses found its place in the systems of Griesinger, Schule, and Krafft-Ebing. The latter's classification, once extremely widespread, divided all so-called functional (i.e., not having a gross organic basis) psychoses into psychoneuroses (diseases of a normally predisposed and properly developed brain) and psychic degenerations, to which were referred 1) resonating insanity, 2) paranoia, 3) periodic psychoses, and 4) psychoses arising from constitutional neuroses: neurasthenia, hysteria, epilepsy, and hypochondria. While Magnan's views still underlie the theoretical and classificatory constructions of most modern French psychiatrists, in Germany, since the victory of the nosological direction, the concept of degenerative psychoses proved superfluous, as all diseases previously referred to it were easily dissolved into Kraepelin's nosological units. At present, only a few opponents of the latter, especially Schroder, Kleist, O. Binswanger, and Kolle, continue to insist on the necessity of preserving the concept of degenerative psychoses. Schroder considers all functional or endogenous mental illnesses in the broad sense of the word to be degenerative psychoses, to which he mainly refers the manic-depressive psychosis group. In a narrower sense, he calls all psychoses from the circle of circular, hysterical, and paranoid forms, which present such characteristic atypical pictures with rich nuances but unclear symptomatology, pictures without sharp boundaries, passing into one another, degenerative psychoses. According to him, such forms occur most frequently among psychoses that proceed periodically, and therefore again are related to manic-depressive insanity. Kleist, rejecting the very existence of manic-depressive psychosis as a single disease, asserts that the forms referred to it (mania, melancholia, etc.) together with a number of others form a large group of diseases, although completely different in symptomatology and pathogenesis, but united by a constitutional factor, autochthonous (spontaneous) origin, cyclic repetition of identical attacks (phases), and in general—opposite to the point of view of Magnan—benign course (lack of progression). These "autochthonous degenerative psychoses" have, according to Kleist, as their basis a special group of "autochthonously labile" constitutions, distinguished by the fact that in them certain brain systems, different for each individual form, prove to be so constitutionally unstable that under the influence of as yet unknown somatogenic factors (Kleist assumes the influence of endocrine poisons specific for each system) they easily come into disorder. As for the genetic basis of degenerative psychoses, each of them corresponds, according to Kleist's terminology, to a special "primitive" genotype. All primitive genotypes tend to unite into "complex" or "composite" ones—an circumstance explaining the polymorphism of degenerative psychoses, i.e., both the successive replacement of one syndrome by another in the same patient, and the frequent occurrence of otherwise difficult to explain transitional and mixed forms. Turning to the clinical side of the question, it is necessary to point out that the usual motivation for separating the group of degenerative psychoses is the impossibility of squeezing all the diversity of endogenous forms of mental illness into the narrow frames of two nosological units—schizophrenia and manic-depressive psychosis. However, the study of the concrete material brought forward by the supporters of the doctrine in question does not confirm the necessity of such a separation: if psychopathy is not counted, the majority of cases described, for example, in Binswanger's large work, without any stretching, up to a progressive course, fit into the frames of schizophrenia, a smaller part refers to certain, though atypical, forms of circular psychosis and epilepsy, and only a few really represent serious diagnostic difficulties, inevitable however in any discipline with the most thorough and detailed classifications. One cannot but agree with Ewald, who says that the doctrine of degenerative psychoses, in no way bringing us closer to understanding the essence of the matter, only replaces several small unknowns by one large one. Similarly, Rudin has already expressed himself against the use of the very term "degenerative psychoses" from a principled point of view. Indeed, the latter would make sense only if it were applied either to all hereditary psychoses (it would then have to be extended to schizophrenia and to diseases such as Huntington's chorea) or only to those which are the result of the appearance of new pathological hereditary qualities, i.e., mutations. In the first case, its use would mean, besides a completely unnecessary change of terminology, a radical revision of already established classifications in psychiatry; in the second case, it would require a precise determination of which psychoses are to be referred to as mutations—a requirement, given the present state of knowledge, completely unfeasible. Finally, it must be emphasized that among the supporters of separating a separate group of degenerative psychoses there was and is no unity of views on the scope or content of this concept. Whatever the case, the extremely energetic efforts of the aforementioned authors, especially Kleist, to revive the doctrine of degenerative psychoses have so far remained fruitless, and the term is gradually falling out of use.