Psychogenies

PSYCHOGENIES, or reactive psychoses, mental disorders caused and conditioned by psychological traumas (see). The term 'psychogenic diseases' was first proposed by Sommer (1894) in relation to an epidemic of convulsions among schoolchildren. For a time, it was incorrectly equated with the narrower concept of hysterical diseases. At present, P. includes a large group of diseases, which in many respects is still a new and insufficiently developed chapter of psychiatry. On the one hand, it includes forms very close in pathogenesis and external manifestations to exogenous types of reactions (shock psychoses), on the other hand, diseases which without any boundaries merge with the everyday mental reactions of psychopaths to life's adversities. P. as a disease must be distinguished both from individual psychogenic symptoms that may occur in any somatic or mental disease, and from provoked or exacerbated by mental trauma endogenous and organic diseases. The main feature of P. is their affective-dynamic nature, reflecting this or that traumatogenic disturbance in the tone of the individual's mental life. These diseases in their structure are close to healthy manifestations, are functional, and since they depend primarily on the structure and content of the psyche, are largely psychologically explicable. It is therefore natural that for defining P. as a clinical unit, following Jaspers, the following psychological criteria are applied: 1) occurrence after a mental trauma, 2) the entire course of the disease is connected with the traumatic experience, with the disappearance of which the disease also passes, and 3) the content of the psychosis follows from the nature of the mental trauma, between which there must be psychologically understandable connections. In many cases, however, the significance of these criteria is limited due to their purely formal nature. In the occurrence of P., both the mental trauma and the properties of the psyche experiencing it have decisive importance. That infinite variety of individual pictures observed in this group of diseases is primarily the result of the immeasurable number of participating factors. Besides the diversity of mental traumas in their content, intensity, duration, etc., everything that makes up the personality and its character is important, namely, first of all, inherited properties of the organism, peculiarities in the somatic and mental development of the personality, past and existing diseases, and finally the entire sum of needs, habits, views, social attitudes that determine a person's usual behavior. The clinical picture of P. allows one to judge as much about the nature of the trauma as about the insufficiency of the traumatized personality itself. This 'predisposition' to psychogenies includes constitutional and generally innate deviations in the form of neuro-vegetative lability, various anomalies of the endocrine glands, further various psychopathic properties and primarily insufficient maturity of the mental structure, affective instability, intellectual deficiency, etc. No less important are the consequences of concussion, infections, chronic intoxications and various organic lesions of the central nervous system, especially arteriosclerosis. P. are often favored by various transient, short-term states caused by previous exhaustion, excitability, etc. Age crises have special significance. It should be considered, however, that under certain conditions, with a sufficiently strong or prolonged trauma, anyone can become ill with one or another P. The individual peculiarities of each case, the slight variability and fluidity of pathological phenomena make any systematics of P. shaky. They do not fit into the usual framework of nosological criteria. In relation to them, as in relation to mental reactions in general, one must abandon a rigid system and strict demarcation of individual forms. They are more conveniently considered as insufficiently delimited syndromes, as 'mental radicals' (Kretschmer). Only schematically can the following 9 forms of P. be distinguished, having common basic properties in origin, structure, and course: 1) shock psychoses, 2) psychogenic depressions, 3) psychogenic paranoids, 4) disorders based on overvalued formations, 5) psychogenic disorders of consciousness, 6) pseudodementias, 7) delusion-like fantasies, 8) induced psychoses (see Induced insanity) and 9) mental epidemics. For a more specific definition of the disease, it is necessary to note not only the form but also the soil on which P. developed. Thus, psychogenic depressions in a cycloid, asthenic, or arteriosclerotic person differ greatly in their basic manifestations. Usually patients with P., especially in mild cases, do not come under medical observation, many are treated not by specialists, and only a small part of them turn to psychiatric outpatient clinics and are placed in hospitals. Thus, an accurate determination of the prevalence of P. does not seem possible. P. can be assessed as a life case of mental disorder, including all moderately expressed diseases. Undoubtedly, the number of P. can sharply increase depending on the increase in mental traumatization of the population during war, unemployment, etc. In the RSFSR according to the statistics of Dr. Prozorov 1927, among hospitalized patients in psychiatric hospitals, these forms of disease constituted among men - 8.2%, among women - 7.5%. Shock psychoses are the result of a sharp mental shock, usually fright during catastrophes. Their pathogenesis is primarily due to damage to the labile vegetative nervous system, especially the vasomotorium. These elementary disturbances of brain activity in their acute degree often lead to clouding of consciousness in the form of lasting for hours or days twilight, delirious, and stuporous states. Unlike purely psychogenic, hysterical ones, they are called 'organic twilight states' (Bonhoeffer). There may be only narrowing of consciousness with automatic actions. After fright and acute mental stress, the so-called paralysis of emotions (Balz) may occur, when in a life-threatening situation no experiences arise except indifferent curiosity about the surroundings. As residual phenomena in an already calm situation, content-specific phobias may appear, arising from sensations reminiscent of the shock experience, often also nightmares. More prolonged states of fear are usually hysterical (the usual front-line hysterization of experience) or manifestations of schizophrenia. Psychogenic depression is the most frequent disorder, the most natural consequence of loss or a distressing situation. The morbidity of it lies mainly in the strength and duration of the experience, depending less on the trauma than on one or another mental insufficiency. Sorrowfulness, unlike circular depression, is connected with specific oppressive experiences and representations. Usually this is resentment, self-pity, inability or unwillingness to reconcile, despair giving way to apathy, shame; alternating with embitterment, etc. The ambivalent, hesitating, needing sympathy psyche of an asthenic is most favorable for such diseases (Lange). The affectively labile psyche of an epileptoid with a tendency to gloomy embitterment, egocentrism leaves a special imprint on the depression, which is often accompanied by a drinking bout or more or less persistent aggressiveness. The peculiarities of the situation in which the depression develops cause even more diversity. Homesickness in a teenager forcibly separated from family and familiar conditions may manifest in unaccountable acts, flight, arson of the house, murder of a child by a nanny, etc. In a prisoner of war, this homesickness may manifest in frequent meaningless escapes. In a prison setting, depression usually has a coating of aggravation, hypochondria and a dense coating of hysterical traits. At the beginning of depressions - usually suicidal thoughts and attempts, which however end unsuccessfully less often than in endogenous depression. For psychogenic states of excitement, their short duration and epileptoid or hysterical coloring are characteristic (Affektepilepsia, furor hystericus). Rarely, mania-like excitations with absurd ideas of greatness, puerilistic behavior and consciousness changed in a hysterical manner may be observed. These states sometimes last for weeks. In hypertymics after some joyful event, excitations may arise that are difficult to distinguish from mild mania: Psychogenic paranoids proceed acutely and as a rule vividly reflect the situation that caused them. They more often develop during years of war, especially in the combat zone, where naturally anxiety for personal safety predominates. Just as often they can be seen in places of deprivation of liberty. A mentally unstable, traumatized by arrest and deprivation of liberty subject soon becomes convinced that everyone is whispering about him, making special signs, hinting at something. Transfer to another cell may lead to the disappearance of delusions. However, suspicion and anxiety often persist for weeks. The most specific for the old prison is the acute paranoid in the form of a hallucinosis of solitary confinement.

Against a background of anxious, tense expectation and melancholy, abundant auditory hallucinations develop quite rapidly, which are usually preceded by heightened hearing and auditory illusions. Patients clearly hear conversations about themselves through the wall, telephone conversations, instructions on how and where to take them and what to do with them, hear the cries of their relatives, and the cries and conversations of fellow prisoners. As fear increases and consciousness changes, visual hallucinations are often also mixed in. Based on these hallucinations, a more or less systematized delusion is constructed. After being transferred to a general cell, the hallucinosis usually disappears quickly; however, in a less severe degree, an outbreak can also occur in a general cell. People with schizoid character traits usually develop hallucinosis in solitary confinement. Arteriosclerosis contributes to a prolonged course. In this case, it is often difficult to differentiate these conditions from truly psychotic ones (schizophrenic process). During the imperialist war of 1914-1918, an acutely occurring delusion of persecution was described in prisoners who found themselves in an unfamiliar environment, "isolated by ignorance of language" (Allers). In other situations, similar paranoid psychoses arise in the hard of hearing and blind, especially during the involutionary period. Reactive paranoid psychoses are particularly distinguished in a yet undefined group of psychopaths in whom a delusion of persecution is formed too easily. The content and course of these are usually no longer later connected with the situation that caused them; in these cases, a tendency toward deep mood disorders, anxiety, and viscosity of experiences often plays a role. In the formation of overvalued ideas as acute psychogenic outbreaks, the character of the person has a predominant role. These diseases are more characteristicogenic than situational in origin. An experience, sometimes objectively insignificant, only with special force mobilizes the constant ability to react with overvalued ideas, i.e., to create an affectively emphasized dominance of a limited circle of representations over the entire psychic life. People with naive paranoid thinking, affectively viscous, purposeful, and fanatical become ill. A typical overvalued formation is litigiousness (see Querulants), arising due to an exclusively affective attitude toward a legal conflict. The psychotic outbreak, gradually increasing, can last for months and years. The presence of arteriosclerotic changes in the psyche contributes to the transformation of an overvalued idea into a persistent delusional system. Similar psychogenic outbreaks can also result from various industrial (trauma) and family conflicts. Hypochondriacal ideas and ideas of jealousy are most often created. Acute psychogenic hypochondria can also arise on the basis of suggestibility and autosuggestibility, especially in oligophrenics. In these cases, the delusion of syphilis infection after casual sexual intercourse is typical. But here too, peculiarities of character (epileptoid or schizoid traits) that predispose to the formation of overvalued ideas are usually noted. Psychogenic, hysterical disorders of consciousness in the form of twilight states, delirium, etc., are concepts that are to a sufficient extent conditional, since there is no true clouding of consciousness here, but one can only speak of a narrowing of it and immersion in fantastic experiences. In them, in the form of a dramatic scene with sharply exaggerated affectivity, the traumatizing events are usually re-experienced. They belong to the "hysterical psychoses" (see), since in them the will to be ill, "flight into illness," striving are revealed, although they are often also found in persons without any hysterical manifestations in the past. These twilight states are usually accompanied by complex visual and auditory hallucinations, as well as delusion-like statements. From the surroundings, patients perceive only what corresponds to their experiences. Sometimes in twilight states, the tendency for reincarnation predominates, when patients portray an animal, a child, etc., crawling on all fours, barking like a dog, imitating childish babble, etc.; or the illness manifests itself as "hysterical fugue," when the patient suddenly runs, as if looking for a place to hide from the unbearable situation that has arisen for them.-Particular forensic-psychiatric interest is represented by psychogenic disorders of consciousness in the form of Ganser's syndrome (see Ganser's symptom), puerilism, and the so-called hysterical or prison stupor. The latter develops either acutely, in the form of affective stupor, or after a period of sullen grumbling and silence, it can last for months, usually with periods of some improvement. Patients remain in a frozen immobility, more often with relaxed musculature and somewhat slowed pulse. At the same time, prolonged retention of urine is not uncommon. Along with this, complete tidiness, purposeful changes in position in bed, submission during care, etc., are noted. These twilight states arise either directly after a traumatic experience, sometimes starting after a hysterical seizure, or after several days (latent period), when mood disorders are usually observed. Their duration ranges from several minutes to several weeks with subsequent complete amnesia for the period of illness. They are often difficult to distinguish from toxic disorders of consciousness, one of the distinguishing features being the absence of phenomena of stupor at that time. They often arise on a schizophrenic and generally invalid basis. It is almost always possible to find a connection between the constitutional properties of the personality and the form of the twilight state (Krasnushkin). It is extremely important to note the role of "habituation" to such illness-like reactions in this case. The formation of artifacts is not uncommon in these cases. In forensic-psychiatric practice, the transfer of such persons from a hospital setting is sometimes used. The basis of pseudodementias, observed almost exclusively in places of deprivation of liberty, protest and the striving created are expressed more prominently. Ideas of innocence, one's own illness, etc., are often observed. They are directly adjacent to the most diverse pictures of "simulated psychoses," where pretense soon becomes automatic, almost involuntary, where the psychic defects always inherent in this personality are revealed and emphasized.-The syndrome of delusion-like fantasies, which most often develops after arrest or in anticipation of it, consists of unstable, dependent on play fantasy statements. This is the interpretation of random impressions and sensations in the sense of persecution, poisoning, hypochondria, or various ideas of greatness with abundant confabulations. It is characteristic that the "delusion" is created before the doctor's eyes and immediately expressed. Sometimes patients "nitpick" at the environment, transforming unpleasant moments of the situation into delusions. Otherwise, they may exhibit behavioral features observed in pseudodementias. Often, patients are capricious, irritable, and deceitful. This syndrome in its nature entirely belongs to hysterical manifestations. "Delusion-like fantasies of degenerates" (Birnbaum) stand out for their vividness, arising in pronounced pseudologists with their fluctuating assessment of their own personality. As for mental epidemics (see Induced insanity), a more common phenomenon is represented by hysterical convulsive epidemics. If in schoolchildren they arise from imitation, the desire to attract attention, then in adults their basis lies in ideas about a sorcerer, damage, demonic possession. Epidemics of mass hysteria are most common. Greater practical significance are epidemics in production, when a factory or enterprise can stop due to mass fainting, convulsive seizures, etc. due to "mass poisoning" by industrial hazards. An impulse to the outbreak is often given by a hysterical person who has experienced a family unpleasantness before going to work and is the first to fall into a hysterical seizure. The course of these epidemics depends largely on the reaction of the administration and sanitary supervision to them. Isolation of the most severe hysterics and calm explanatory conversation quickly localize and stop the epidemic. Therapy for P. naturally consists first, if possible, in eliminating the moments that traumatize the psyche. The most effective means is rational psychotherapy with attempts at distraction, persuasion, suggestion, and the creation of healthy work attitudes. Usually, therapy requires great individualization. Acute or prolonged cases of P. should be placed in psychiatric institutions, usually of a sanatorium type. For insomnia, fears, melancholy, disorders of the autonomic nervous system, warm baths, hypnotics (Veronal, Luminal) and opiates are indicated.-The prognosis for P. is generally favorable, however, they can contribute, on the one hand, to the pathological development of the personality, and on the other, to premature aging of the body due to prolonged affective tension.