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Pseudopsychosis: A reexamination of the concept of hysterical psychosis
Pseudopsychosis: A Reexamination of the Concept of Hysterical Psychosis Emmett
R. Bishop, Jr. and A. Roland Holt
I
T HAS LONG been accepted by most psychiatrists that symptoms mimicking organic disease can arise through psychological mechanisms. These simulated physical symptoms acquire a multitude of forms and have been referred to historically as conversion symptoms. Conversion symptoms can often lead to diagnostic and management problems. For example, pseudoseizures in a patient for whom there is diagnostic uncertainty may create management problems for the neurologist who is frustrated by his inability to control the patient’s “epilepsy” with anticonvulsive agents. The need to determine the presence of the pseudoseizures is self-evident in that psychological rather than pathophysiologic factors are to be addressed. A simultaneous encephalographic monitoring during the seizure activity will, of course, fail to demonstrate a pathophysiologic correlate of the seizure, and there will be little question about exploring psychogenic factors. A conversion symptom, no matter how suggestive of physical disease, is inauthentic-a simulation. With these symptoms, one is dealing not with psychiatric disease whose symptoms represent dissolution of function: rather, as Slater’ has asserted that one is confronted with the opposite situation, the facsimile of disease orchestrated through a healthy peripheral nervous system. An analogous situation could possibley exist, for example, with schizophrenia where there is some evidence albeit inconclusive, for biochemical and neurophysiologic correlates. As with any disease, its symptomatology is subject to simulation, and some patients may exhibit motor behavior and/or report hallucinations and delusions similar to those in schizophrenia. These pseudosymptoms could serve some unconscious or, perhaps, conscious motive. Irrespective of motivational factors, such patients would no more have a schizophrenic disorder than a patient with pseudoseizures has epilepsy. If, in fact, such a group of patients exists in which psychosis is simulated, they might have features in common with patients manifesting somatoform disorders and possibly share common etiological factors. That diagnosticians can be fooled in certain settings by actors reporting hallucinations has been shown by Rosenhan.’ Obviously, attempts to identify the essential nature of any psychowill be hampered by the inclusion of tic process, such as schizophrenia, patients simulating psychosis in research data. While this may be less of a problem with more stringent diagnostic criteria currently in use, treatment
From the Departments of Psychiatry, Medical College of Georgia, Augusta, Georgia, and St. Vincent’s Hospital, New York. Emmett R. Bishop, Jr., M.D.: Medical College ofGeorgia, Augusta, Georgia; A. Roland Holt, M.D.: St. Vincent’s Hospital. New York. Address
reprint requests
to Emmett R. Bishop, Jr. M.D.,
Department
of Psychiatry,
Medical
College of Georgia, Augusta, Georgia 30912. @ 1980 by Crane & Stratton, Inc. 0010-440X180/2102-0008$02.00/0 150
Comprehensive
Psychiatry,
Vol. 21, No. 2 (March/April),
1980
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decisions are often made on the basis of clinical pictures which only roughly approximate ideal diagnostic types. Thus, the simulation of psychosis, i.e., pseudopsychosis, becomes an even more practical diagnostic problem. The notion of pseudopsychosis, however, calls to question the very nature of psychosis. Is psychosis a dissolution of brain functioning or a learned social role? If the former is the case, the distinction between pseudopsychosis and psychosis is valid. On the other hand, if psychotic behavior is a learned social role, then all psychotic phenomena unrelated to course brain disease may be interpreted as having some adaptive goal in terms of personal needs. Defining psychosis is no simple task. Manshreck has recently noted that psychosis is generally held to involve: (I) loss of reality testing, (2) pervasive dysfunctioning in all spheres of the personality, (3) disturbed and disordered behavior, and (4) a clinical picture in which the form of the symptoms is not understandable in the context of the patient’s premorbid personality functioning or life situation.” The criteria above, for whatever they lack in specificity, do provide a rough basis for examining the authenticity of clinical phenomena. For a concept of pseudopsychosis to have validity, the criteria above should be absent except for the criterion of disturbed or disordered behavior, which is an essential common feature of psychosis and any putative pseudopsychosis. This paper will attempt to review the world literature on “hysterical psychosis” and related syndromes and explore their relationship, if any, to the somatoform disorders proposed in the Diagnostic and Statistical Manual-III (DSM-III)’ of the American Psychiatric Association.’ We will report briefly our own experiences with cases felt to represent pseudopsychoses. AN HISTORICAL
VIEW
Hysterical psychosis is an unofficical clinical diagnosis to which little attention has been paid since the turn of the century. In the early 1900s a number of German and French writers reported hysterical syndromes with such labels as hysterical delusional state (ddire hystirique, hysterischen Wcrhnsinn), hysterical insanity (fofie hystkriyue. hysterischen Zrrrsein) and hysterical melancholia or hysterical mania, among other.“.” After nearly 50 years of relative obscurity, the term hysterical psychosis was reexamined by Follin, Chazaud, and Pilon.: These writers explained the long absence of hysterical psychosis from the literature by noting that under the influence of Freud and his followers, hysterical manifestations had been “neuroticized” with subsequent incorporation of “psychotic” presentations into the grouping of schizophrenic psychoses or acute psychoses. Emil Kraepelin acknowledged the existence of psychotic-like symptoms in hysteria and contrasted them with dementia praecox.7 On the other hand, Eugene Bleuler took a different view, insisting that “hysterical psychosis” represented merely the occurrence of schizophrenia in a personality which was premorbidly hysterical.x As suggested by Sirois, the concept of hysterical psychosis was probably poorly accommodated by Freudian psychoanalysis or by descriptive psychiatry in the tradition of Kraepelin.g In 1964, Hollender and Hirsch defined hysterical psychosis using the following criteria: (1) sudden, dramatic onset, (2) temporal relationship to a profoundly upsetting event or circumstance, (3) the occurrence of hallucinations,
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delusions, depersonalization, or bizarre behavior in the absence of a major thought disorder or flattened affect (with affective volatility being more usual), (4) duration of one to three weeks with sudden, dramatic clearing and no residue, and (5) occurrence in hysterical personalities (predominantly women) or those with elements of this character type.‘O These authors endorsed the Freudian notion of “intrusion of unconscious material” as underlying the hysterical psychosis. Prinquet framed the hysterical psychosis in terms similar to Hollender and Hirsch.” He characterized the delusional picture further by the presence of mystical, religious, and sexual themes. The patients responded to low dose neuroleptics and returned to their premorbid state, but were subject to frequent and unforseen recurrences. The hysterical diathesis was seen in the suggestibiltendencies, sexual dysfunction, egocentrism, dramatizaity, “mythomaniacal” tion, and affective lability. Additionally, these patients were said to suffer diffuse and persistent anxiety and diverse symptomatology, including conversion symptoms, depressive state, twilight states, suicide attempts, and other behavioral disturbances. These patients, like those described by Hollender and Hirsch, never lost contact with reality. In 1969, Hollender and Hirsch revised their original findings delineating three different types of hysterical psychosis. I2 The first grouping, called “culturallywas developed, apparently, in response to the ansanctioned behavior” thropological work of Langness13 and subsumes such “culturally-bound” phenomena as latah, amok, negi negi, and whitiko psychosis. These phenomena were explained by them as institutionalized coping behaviors, created and maintained by the cultures involved. of psychotic behavior” is Their second category entitled “appropriation essentially a “conversion process taking the form of psychotic symptoms and behavior.” They contrast this with their third category, which they call “true psychosis,” and which is essentially the “surfacing of unconscious material” model, offered in their 1964 paper. Thus, in category two, “appropriation of psychotic behavior,” repression is reinforced, rather than disrupted, and the primary mechanism is strongly defensive. This suggestion is most interesting in light of the fact that hallucinations have also been reported to have arisen by a conversion mechanism in patients without more severe pathology, by Fitzgerald and Wells,14 McKegney,15 and Levinson.16 We might remark here, however, that Siomopoulus17 has recently challenged this conversion interpretation in patients with hysterical psychosis, preferring to stress instead a “linguistic shift” from the thought content frame of reference to that of sensory experience. Reports of hysterical psychotic-like syndromes have, by no means, been confined to the acute reactive forms discussed above. A number of chronic and subchronic forms have been discussed by anthropologists. Two culture-bound syndromes, latah and imu, have been observed to have chronic, deteriorating courses and Langness has suggested that chronicity may be a function of the social response to the illness.13 Examples of chronic psychotic-like behavior of a hysterical nature are possibly found in Western society as well. This is evidenced in the series of patients reported by Mallett and Gold.lR
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153
All of the patients reported by Mallett and Gold were women, and 10 of the 13 were classed as hysterical personalities. In marked contrast to Hollender and Hirsch’s definition, however, the onset in these cases was not acute, but was “insidious, with increasing depression, apathy, anergia, inability to care about work or personal relationships.” These patients also differed from the definition in that there was not necessarily any true resolution of their symptoms. These workers report that continued social deterioration was the outcome in 8 of their 13 patients, and that suicide was the result in 3 more. It should be noted that although these patients demonstrate a deteriorating course, the notion of underlying schizophrenia was rejected for valid clinical reasons, including absence of thought disorder and the presence of affective lability. One might also point out the lack of corroborative family history of schizophrenia in all but one of their 13 subjects. It is also interesting to note that these patients had little conviction of the reality of their hallucinations. Another very interesting point about these cases of Mallett and Gold is that the features of Briquet’s syndrome, or hysteria as defined by Guze, are present in many of the patients.‘” Seven of the cases of Mallett and Gold had histories of multiple somatic complaints leading to frequent visits with the general practitioner. Frigidity was a constant feature in all cases. All cases had hysterical personality traits and ten cases were diagnosed as such. (Hysterical personality occurs in two-thirds of patients with Briquet’s syndrome.)20 Moreover, a family history of male psychopathy was notable in several cases of Mallett and Gold, suggesting a similar genetic relationship as that hypothesized in Briquet’s syndrome.20 Another investigator, Dalle, discussed a group of cases given diagnoses of chronic hallucinatory psychosis, a diagnosis maintained distinct from schizophrenia by the French school.“* Dalle felt that a number of these cases (7%) with coexisting hysterical personality were qualitatively different from the others. These cases did not have the thought disturbances (incoherence, autism, and lack of judgement) characteristic of schizophrenia. Antecedent “conversion” symptoms coupled with apparent purposes of hallucinatory experiences lead Dalle to postulate a mechanism of “psychic conversion.” Interestingly, although Dalle reports only three cases in detail (two male), we perceive in this series of patients, as well, some of the features of Briquet’s syndrome including conversion symptoms, sexual dysfunction, and menstrual difficulties in the female. More recently, a paper by Spiegel and Fink provides additional evidence supporting the validity of the concept of a hysterical psychosis.” They report increased hypnotic suggestibility by Hypnotic Induction Profile in two cases diagnosed as hysterical psychoses. Moreover, they compare this heightened suggestibility to the reduced suggestibility reported in schizophrenic patients-an
interesting
contrast.
A DEFINITION
OF PSEUDOPSYCHOSIS
Having reviewed the development of the concept of hysterical psychosis, we will now endeavor to define, operationally, pseudopsychosis. We use the term pseudopsychosis to avoid the use of the ambiguous word hysterical and to distinguish our concept from true psychosis as we have discussed above. The
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Table
1. Operational
Definition for Pseudopsychosis
A. Predominant symptoms are delusions or hallucinations 6. Absence of derailment of thought and blunting of affect C. Psychologic factors are judged to be etioiogically involved in the symptoms as evidenced by: 1. A temporal relationship between psychologically meaningful environmental stimuli and initiation or exacerbation of the symptom 2. Symptoms enable the individual to avoid some activity that is noxious to him 3. Symptoms enable the individual to get support from the environment that otherwise might not be forthcoming, i.e., disability, solicitude D. At least two of the following that can not be explained on a medical basis during the patient’s life: 1. Visual hallucinations 2. Pains or bodily symptoms suggesting loss or alteration of function 3. Memory losses or amnesia 4. Homosexual preoccupation or involvement, or other problems of a sexual nature 5. Histrionic or antisocial personality E. Does not meet criteria for organic brain syndromes, schizophrenia, or affective disorder
definition is presented in Table 1. It follows the style of DSM-III and bears similarity to the operational criteria for the two somatoform disorders, conversion disorder and psychogenic pain disorder.-’ This definition of pseudopsychosis has several advantages over the widely cited Hollender and Hirsch definition. In addition to the explicit motivational criteria, the definition of pseudopsychosis does not limit itself to acute states, precipitating events are not required, and additional descriptors are provided to further define the syndrome. Furthermore, the diagnostic process is more explicit. THE DATA
Our survey of the literature reveals no systematic controlled study of cases which might be construed to represent pseudopsychotic behavior as we have discussed. There are, however, a number of anecdotal reports and brief case presentations. If our definition of pseudopsychosis is applied retrospectively to the cases reported in the literature (Table 2), most conform reasonably well. Our own cases meeting these criteria are reported in Table 3. Tables 2 and 3 reflect age, sex, type of hallucinations, and associated state in reported cases. Other common features are included under comments. The Literature
Cases
The average age for all patients (male and female) is 30.9 years (excluding one of Follin’s cases and Martin’s case, where no age is given). For the 40 women with reported ages, the average age is 29.8 years, and for the 7 men of stated age it is 39.6. Of 49 reported patients, 41 (83.7%) were female. Of the 39 cases where hallucinations were specified, 20 (51.3%) reported visual hallucinations and 21 (53.8%) reported auditory ones. Eleven patients (28.2%) reported both auditory and visual hallucinations. Ten patients were likely to have oneiroid states (20.4%), and 4 (8.2%) could have had parahypnic onset or exacerbation of illness. Of 18 papers, 4 (38.9%) report chronic courses in their patients, while 7 (38.9%) report subacute or periodic courses. Seven papers report that only acute courses were seen (38.9%). Of 18 papers, 9 (50%) report histories of
Table 2. Type of Hallucinations
Authors Follin et al.”
Hollender and HirschlO Mallet-t and Gold’Y
CsssS Age/Sex 55 M 30 F 48 M 29 M ?M
Hallucinations Visual Auditory
+ + +
+ +
+
+
I
13 cases, all females, mean age = 29 38 F 21 F
Levinsonl”
29 F
Cottraux et al.3R
37 F 42 F
Hirsch and Hollender’”
19 F 47 F
Dalle”’
44 M 65 F 40 M
Richman and White=
16 20 27 32
F F F F
?F
+
Comments Acute, subacute and chronic course, homosexual themes, conversion or somatization, memory loss
+ + +
+
Acute course Chronic course, somatization, sexual maladjustment
+
?+
+ +
+ +
+
+
?i
Acute course, sexual maladjustment, homosexual themes Chronic course Conversion symptoms, periodic and subacute courses
?+ +
Conversion pain, acute courses
+ +
Chronic courses, conversion symptoms, homosexual themes +
Acute courses
+
Unspecified + Unspecified
Acute course
+ +
MentzoQ
32 F 32 F
Unspecified Unspecified
Prinquet”
15F
+
Miller:‘”
30 M
+
SiroisY
29 F
+
i
Fitzgerald and Wells”
31 F
+
+
Spiegal and Fink”
15 M 31 F
Unspecified +
Cavenar et al.“’
21 23 24 30
Totals
Associated State Oneiroid Parahypnic
m+
33 F 21 F
F F F F
States Occurring in Cases of Hysterical Psychosis
+ +
45 F 24 F
McKegney’j
Mar-tin”*
and Superimposed
+
Acute and subacute courses, somatization Periodic and subacute course
+
Subacute course. amnesia, conversion symptoms Acute course, pseudo-homosexuality Acute course, somatization +
lntermittant course, amnesia, acute course, somatization I
?+
Acute courses
?+ ?i 20
Subacute course, somatization
21
10
4
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Table
3. Cases Seen by Authors Meeting the Operational CEA?S
Initial Diagnosis
Age/Sex
Hallucinations
Auditory
Associated
Visual
Hysterical psychosis
20 M
Hysterical psychosis
25 M
+
+
Chronic undifferentiated schizophrenia
28 M
+
+
Paranoid schizophrenia
12 F
+
+
Acute schizophrenia
43 F
+
Acute psychosis
44F
+
Acute schizophrenia
48F
Oneiroid
Definition of Pseudopsychosis State
Parahypnic
+
+
Comments
Acute course, antisocial personality
+
+
Probable Briquet’s chronic course, conversion symptoms
Chronic course, borderline personality, hysterical features, homosexual themes, conversion symptoms
+
+
Subacute course, phobias, hysterical personality features Acute course, recurrent episodes, antisocial personality, dissociation
+
Acute course following death of mother Acute course, recurrent episodes, conversion symptoms, hysterical personality features
somatization in their patients. Three of the papers report homosexual ideation in some of their patients, while one reports pseudohomosexuality. Sexual conflicts or maladjustments present in the vast majority of patients are not tabled. Personal
Cases
Of the seven cases that we have seen that meet the criteria in Table 1 for the the average age for all patients (male and diagnosis “pseudopsychosis,” female) is 31.4. For the three males, the average age was 24.3, and for females, 36.8. Of the seven patients, four (57.1%) were women and three (42.8%) were men. Of these seven patients, four had acute courses (57.1%) and of these four, two
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had recurrent episodes at later dates. One patient (14.3%) had a subacute course, and two patients (28.6%) a chronic one. Four patients (57.1%) reported auditory hallucinations and six reported visual ones (85.7%). Three patients (42.8%) reported both auditory and visual hallucinations. Three patients (42.9%) reported parahypnic hallucinations. and two (28.6%) experienced oneiroid states. Of these seven patients, two had hysterical personalities, two had borderline personalities with hysterical features, and two were antisocial personalities. NOSOLOGICAL
CONSIDERATIONS
In the United States, where little nosologic distinction is made between psychogenic and endogenous psychoses, or between acute or chronic psychoses. pseudopsychoses may often be diagnosed as a schizophrenic psychosis. This would seem to coincide with our own observations in Table 3 where initial diagnoses prior to our evaluation are reported, as well as with results found in numerous reports by others in our literature survey. It is also conceivable that the diagnosis of affective psychosis may claim a substantial number of these cases. In the new DSM-III categories, acute pseudopsychoses would be placed under the brief reactive psychoses on Axis I, while Axis II would indicate an underlying hysterical personality. Manifestations with a duration longer than one week would not be easily categorized. Subacute (less than 6 months) and chronic cases would be relegated to the atypical category and, therefore, would lose special designation. The special category of brief reactive psychosis is an improvement over the lack of designation that existed before, but does not identify the inauthenticity of many brief states or accommodate variability in the course of many pseudopsychoses reported in the literature. PSEUDOPSYCHOSIS
AND REACTIVE
PSYCHOSIS
Interestingly, many clinicians in the United States equate the term hysterical psychosis with the term reactive psychosis, as, for example, Pincus and Tucker do in their discussion of the differential diagnosis of schizophrenia.z3 Hollender and Hirsch also recognized a possible relationship to the reactive psychoses in referencing the work of Astrup et al.24 Regarding this issue, there would seem to be merit in maintaining a distinction between psychogenic or reactive psychoses in terms of the hypothesized nature of the symptoms. This conceptual distinction would consider the symptoms, in the former category, as manifestations of dissolution or disequilibrium of mental function, as conceptualized by Eyl” and, in the latter category, as motivationally determined phenomena initiated and maintained by psychosocial factors. While such a distinction may be difficult to establish in cases of acute onset following meaningful environmental events, we feel that it might serve as a diagnostic principle that could aid in delineating more homogeneous groups of patients. This issue of true psychosis versus pseudopsychosis was approached by Hirsch and Hollender.‘” Concordant with the conceptual distinctions of this paper, they claimed one of the three types of hysterical psychosis as being
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“true psychosis.” This group of psychoses probably overlaps with the Scandanavian concept of psychogenic psychosis. Whether hysterical psychoses of this type should be delimited from the psychogenic psychoses is debatable. Even if the psychogenic psychoses are valid entities, the so-called hysterical psychosis could be none other than the concurrence of a psychogenic psychosis and a “hysterical” personality. Striimgren found no relationship, however, between personality and the form of reactive psychoses.26 What remains of Hirsch and Hollender’s types of hysterical psychoses are the “culture-bound” syndromes and “conversion” psychoses with appropriation of psychotic behavior. These latter groupings would be included in our concept of pseudopsychosis. Although our usage of the term pseudopsychosis is conceptually distinct from psychogenic psychosis, it probably merges with the Ganser pseudodementia much as “conversion hysteria” often shades into malingering in actual clinical practice. Ganser referred to his cases, interestingly enough, as “hysterical twilight states.” The obvious goals in the Ganser situation are avoidance of punishment and absolution from responsibility for one’s actions. Although Ganse? did not feel that malingering played a major part in the clinical picture, it is difficult to see why it would not. When one examines the data from the case reports of hysterical psychosis in the literature, a possible relationship to the somatoform disorders emerges. One can analogize the relationship of acute pseudopsychoses to chronic pseudopsychoses with that of conversion disorder to Briquet’s syndrome. (The terms “acute” and “chronic” hysteria have been used.Y8 Conversion symptoms, as defined by Guze,ls are often transient phenomena which resolve without sequelae in a number of patients followed up five years later.2g These cases would correspond to the acute forms of pseudopsychosis, such as those defined descriptively by Hollender and Hirsch.12 With regard to “chronic hysteria,” Briquet’s syndrome is, of course, the operationally defined somatoform disorder that would correspond to the chronic pseudopsychosis such as that described by Mallett and Gold’” and Dalle.21 As we have discussed, both acute and chronic forms of pseudopsychosis are often accompanied by conversion symptoms and other characteristics held in common with their possible somatic counterparts. DISCUSSION
Temoshok and Attkisson30 have ordered hysterical phenomena with regard to course as we discussed above. These authors felt that hysterical phenomena align themselves more naturally along a chronic-acute axis than a psychoticneurotic axis. We concur with this conceptualization because we believe that the phenomena under question are not true psychoses in the usual sense of the word, as elaborated earlier. The usual dichotomization of mind and body seems to naturally lead to a psychotic-neurotic categorization and its implications when dealing with pseudosymptoms. We feel that the choice of symptoms in either the somatic or mental sphere probably depends more on social factors rather than on any intrinsic abnormality of the brain. That is, patients with pseudopsychotic symptoms probably share in common similar pathogenic
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159
mechanisms found in patients manifesting somatoform disorders. (See Pilowsky’s classification of abnormal illness behavior.31) The concept of pseudopsychosis that we have discussed would seem to deserve further verification for several reasons. First, the treatments for various major psychoses are obviously inappropriate and possibly harmful for individuals who do not have alteration of brain functioning. Second, more of society’s disenfranchized persons are likely to shift coping strategies that use illness behavior from the realm of the somatic symptom to that of the psychic symptom, because there is less exactitude in psychiatric diagnosis, and because society is less naive about bodily functioning and illness today that it has ever been. Third, the widespread availability of mental health services and decreased stigmatization of mental illness will tend to encourage those disenfranchized individuals of society to enlist the support of public services by way of simulated psychotic illness, much in the same manner that patients with conversion symptoms have done within the sanctions of the sick role. Although the lack of systematic controlled studies of pseudopsychotic behavior precludes definite conclusions, our perusal of the literature and our own case observations yield some interesting and testable hypotheses. Two hypotheses arising out of this preliminary data relate to the suggested accentuation of symptomatology during the parahypnic phases of wakefulness, and relate to the relatively higher frequency of visual hallucinations. The common visual nature of the hallucinations and their accentuation in the parahypnic phases of wakefulness are particularly notable in our survey. Ey et al.“” made this latter point in discussing acute delusional psychoses. Although we have not seen this explicitly stated, onset of the hysterical psychosis in a parahypnic phase would seem to be present in several case reports,‘(‘,‘4 -Ii~~~~ ‘lpincluding three of our own. It has been stated that hypnogogic hallucinations are seen frequently in “hysterical patients.““4 Visual hallucinations, whether hypnogogic or diurnal, are said to be more typical of hysterical patients”” and they are seen quite commonly in the cases listed in Tables 2 and 3. Visual hallucinations are seen in 51% of the cases reported. Oneiroid and parahypnic phenomena may be underrepresented in these cases. As we have discussed earlier, pseudopsychotic behavior is probably similar to somatoform behavior. The association of hysterical psychoses with conversion symptoms or somatization is frequent in our cases and those of the ~~~~~~~~~~~~.9.li,~~,lI,l7.lX,~l.~.~~~~ This association should be studied further on well-defined samples of patients. Although the literature invariably links the hysterical psychosis to the hysterical personality, this may not be necessarily so. In our series we found hysterical personality features in four of seven cases-certainly not an unfailing observation. Quite interestingly, we found two antisocial personalities. In one case we could make no clear decision about personality type. It is entirely possible that, as with conversion reactions. there is no obligatory relationship between pseudopsychoses and hysterical personality. Conversion symptoms are frequent in individuals diagnosed as antisocial personalities,“7 and it is not surprising that two antisocial personalities presented psychotic-like behavior. Briquet’s syndrome (hysteria) apparently shares a genetic etiology with the antisocial personality”’ and may enter the
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picture as we have seen in Case 2. While the precise nature of the relationship between these various clinical syndromes remains to be clarified, it is possible to utilize a clinical triad of psychotic-like behavior, somatization, and histrionic or antisocial personality as a red flag for pseudopsychosis. In this paper we have tried to stimulate interest and to raise awareness of some patients who may be simulating psychotic illness. Much remains to be learned about these patients in terms of scientific explanation. Perhaps, if we define them more precisely we may begin to identify those intrinsic and extrinsic factors interacting to produce pseudopsychotic phenomena. REFERENCES 1. Slater E: The diagnosis of “hysteria.” Br Med J 1:1395-1399, 1965 2. Rosenhan DL: On being sane in insane places. Science 180:250-258, 1973 3. Manschreck TC: Acute psychosis: Attempts at clarification, in Manschreck TC, Kleinman AM (eds): Renewal in Psychiatry. Washington, Hemisphere Publishing, 1977, pp. 45-96. 4. Task Force on Nomenclature and Statistics. DSM III draft. Washington, DC, American Psychiatric Association, 1978 5. Follin S, Chazaud J, Pilon L: Cas cliniques de psychoses hysteriques. Evolution Psychiatrique, 261257-286, 1961 6. Mentzos S: Zur psychodynamik der sogenannten “hysterischen” psychosen. Nervenart 44:285-291. 1973 7. Kraepelin S: Dementia Praecox and Paraphrenia. Huntington, New York, Krieger, 1978. pp. 270-272 8. Bleuler E: Dementia Praecox and the Group of Schizophrenias. New York, International Universities Press. 1950, p. 289 9. Sirosis F: La psychose hysterique. Psychiat J U Ottawa 2:72-77, 1977 10. Hollender MH, Hirsch SJ: Hysterical psychosis. Am J Psychiatry 120:1066-1074, 1964 11. Prinquet G: A propos d’un cas de psychose hysterique. Nouv Presse Med 6:441-443, 1977 12. Hirsch SJ, Hollender MH: Hysterical psychosis: Clarification of the concept. Am J Psychiatry 125909-915, 1969 13. Langness LL: Hysterical psychosis: the cross-cultural evidence. Am J Psychiatry 124:143-152, 1967 14. Fitzgerald BA, Wells CE: Hallucinations as conversion reaction. Dis Net-v Syst 38:381383, 1977 15. McKegney FP: Auditory hallucination as
a conversion symptom. Compr Psychiatry 8:80-89. 1967 16. Levinson H: Auditory hallucinations in a case of hysteria. Br J Psychiatry 112:19-26, 1966 17. Siomopoulus V: Hysterical psychosis: Psychopathological aspects. Br J Med Psycho1 44:95-100, 1971 18. Mallett BL, Gold S: A pseudoschizophrenic hysteria syndrome. Br J Med Psycho1 37159-70, 1964 19. Guze SB: The validity and significance of the clinical diagnosis of hysteria (Briquet’s syndrome). Am J Psychiatry 132:138-141, 1975 20. Cloninger CR: The link between hysteria and sociopathy: An integrative model of pathogenesis based on clinical. genetic and neurophysiological observations, in Akiskel HS Weeb WL teds): Psychiatric Diagnosis: Exploration of Biological Predicators. New York. Spectrum, 1978, pp. 270-272 21. Dalle B: Syndrome hallucinatoire chronique et hysteric. Evolution psychiatrique 34:339-359, 1969 22. Spiegel D, Fink R: Hysterical psychosis and hypnotizability. Am J Psychiatry 136:777781, 1979 23. Pincus JH, Tucker GJ: Behavioral Neurology. New York. Oxford University Press, 1978 24. Astrup C, Fossum A, Homboe R: Prognosis in functional psychoses. Springfield, Ill. Charles C Thomas, 1962, pp. 11l-161 25. Ey H: Outline of an organo-dynamic conception of the structure, nosography, and pathogenesis of mental disease, in Natanson M (ed): Psychiatry and Philosophy, New York, Springer-Verlag, 1969 26. StrSmgren E: Psychogenic psychoses, in Hirsch SR, Shephard M (eds): Themes and Variations in European Psychiatry. Charlottesville, University of Virginia Press. 1974, pp. 97-117
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27. Gamer SJM: A peculiarhysterical state, in Hirsch SR, Shepherd M (eds): Themes and Variations in European Psychiatry. Charlottesville University of Virginia Press, 1974, pp. 67-73 28. Meares R, Horvath T: ‘Acute’ and ‘chronic’ hysteria. Br J Psychiatry 121:653-657 29. Carter AB: The prognosis of certain hysterical symptoms. Br Med J i: 1076-1079. 1949 30. Temoshok L, Attkisson CC: Epidemiology of hysterical phenomena: Evidence for a psychosocial theory, in Horowitz MJ (ed): Hysterical Personality. New York, Jason Aronson, 1977. pp. 145-222 31. Pilowsky I: A general classification of abnormal illness behavior. Br J Med Psycho1 51:131-137, 1978 32. Ey H. Bernard P, Brisset C: Manuel de Psychiatric. Paris, Masson, 1974, pp 293-303 33. Richman J, White H: A family view of hysterical psychosis. Am J Psychiatry 127:280-285, 1970 34. Linn L: Clinical manifestations of psychiatric disorders, in Freedman AM, Kaplan
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HI, Sadock BJ (eds): Comprehensive Textbook of Psychiatry (ed 2). Baltimore, Williams & Wilkins, 1975 pp. 783-825 35. Nemiah JC: Hysterical neurosis. conversion type. in Freeman AM, Kaplan HI. &dock BJ (eds): Comprehensive Textbook of Psychiatry (ed 2). Baltimore, Williams & Wilkins. 1975. pp. 1208-1220 36. Cottraux J, Reyss-Brion MP. Massot D: La notion de psychose hysterique. J Med Lyon 50:959-965, 1969 37. Guze SB, Woodruff RA, Clayton PH: A study of conversion symptoms in psychiatric outpatients. Am .I Psychiatry 128:643-646, 1971 38. Martin PA: Dynamic consideration of the hysterical psychosis. Am J Psychiatry 128:745748, 1971 39. Miller RD: Pseudohomosexuality in male patients with hysterical psychosis: A preliminary report. Am J Psychiatry 135: 112-113, 1978 40. Cavenar JO. Sullivan JL, Maltbie. AA: A clinical note on hysterical psychosis. Am J Psychiatry 136:830-832, 1979
R. Bishop, Jr. and A. Roland Holt
I
T HAS LONG been accepted by most psychiatrists that symptoms mimicking organic disease can arise through psychological mechanisms. These simulated physical symptoms acquire a multitude of forms and have been referred to historically as conversion symptoms. Conversion symptoms can often lead to diagnostic and management problems. For example, pseudoseizures in a patient for whom there is diagnostic uncertainty may create management problems for the neurologist who is frustrated by his inability to control the patient’s “epilepsy” with anticonvulsive agents. The need to determine the presence of the pseudoseizures is self-evident in that psychological rather than pathophysiologic factors are to be addressed. A simultaneous encephalographic monitoring during the seizure activity will, of course, fail to demonstrate a pathophysiologic correlate of the seizure, and there will be little question about exploring psychogenic factors. A conversion symptom, no matter how suggestive of physical disease, is inauthentic-a simulation. With these symptoms, one is dealing not with psychiatric disease whose symptoms represent dissolution of function: rather, as Slater’ has asserted that one is confronted with the opposite situation, the facsimile of disease orchestrated through a healthy peripheral nervous system. An analogous situation could possibley exist, for example, with schizophrenia where there is some evidence albeit inconclusive, for biochemical and neurophysiologic correlates. As with any disease, its symptomatology is subject to simulation, and some patients may exhibit motor behavior and/or report hallucinations and delusions similar to those in schizophrenia. These pseudosymptoms could serve some unconscious or, perhaps, conscious motive. Irrespective of motivational factors, such patients would no more have a schizophrenic disorder than a patient with pseudoseizures has epilepsy. If, in fact, such a group of patients exists in which psychosis is simulated, they might have features in common with patients manifesting somatoform disorders and possibly share common etiological factors. That diagnosticians can be fooled in certain settings by actors reporting hallucinations has been shown by Rosenhan.’ Obviously, attempts to identify the essential nature of any psychowill be hampered by the inclusion of tic process, such as schizophrenia, patients simulating psychosis in research data. While this may be less of a problem with more stringent diagnostic criteria currently in use, treatment
From the Departments of Psychiatry, Medical College of Georgia, Augusta, Georgia, and St. Vincent’s Hospital, New York. Emmett R. Bishop, Jr., M.D.: Medical College ofGeorgia, Augusta, Georgia; A. Roland Holt, M.D.: St. Vincent’s Hospital. New York. Address
reprint requests
to Emmett R. Bishop, Jr. M.D.,
Department
of Psychiatry,
Medical
College of Georgia, Augusta, Georgia 30912. @ 1980 by Crane & Stratton, Inc. 0010-440X180/2102-0008$02.00/0 150
Comprehensive
Psychiatry,
Vol. 21, No. 2 (March/April),
1980
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decisions are often made on the basis of clinical pictures which only roughly approximate ideal diagnostic types. Thus, the simulation of psychosis, i.e., pseudopsychosis, becomes an even more practical diagnostic problem. The notion of pseudopsychosis, however, calls to question the very nature of psychosis. Is psychosis a dissolution of brain functioning or a learned social role? If the former is the case, the distinction between pseudopsychosis and psychosis is valid. On the other hand, if psychotic behavior is a learned social role, then all psychotic phenomena unrelated to course brain disease may be interpreted as having some adaptive goal in terms of personal needs. Defining psychosis is no simple task. Manshreck has recently noted that psychosis is generally held to involve: (I) loss of reality testing, (2) pervasive dysfunctioning in all spheres of the personality, (3) disturbed and disordered behavior, and (4) a clinical picture in which the form of the symptoms is not understandable in the context of the patient’s premorbid personality functioning or life situation.” The criteria above, for whatever they lack in specificity, do provide a rough basis for examining the authenticity of clinical phenomena. For a concept of pseudopsychosis to have validity, the criteria above should be absent except for the criterion of disturbed or disordered behavior, which is an essential common feature of psychosis and any putative pseudopsychosis. This paper will attempt to review the world literature on “hysterical psychosis” and related syndromes and explore their relationship, if any, to the somatoform disorders proposed in the Diagnostic and Statistical Manual-III (DSM-III)’ of the American Psychiatric Association.’ We will report briefly our own experiences with cases felt to represent pseudopsychoses. AN HISTORICAL
VIEW
Hysterical psychosis is an unofficical clinical diagnosis to which little attention has been paid since the turn of the century. In the early 1900s a number of German and French writers reported hysterical syndromes with such labels as hysterical delusional state (ddire hystirique, hysterischen Wcrhnsinn), hysterical insanity (fofie hystkriyue. hysterischen Zrrrsein) and hysterical melancholia or hysterical mania, among other.“.” After nearly 50 years of relative obscurity, the term hysterical psychosis was reexamined by Follin, Chazaud, and Pilon.: These writers explained the long absence of hysterical psychosis from the literature by noting that under the influence of Freud and his followers, hysterical manifestations had been “neuroticized” with subsequent incorporation of “psychotic” presentations into the grouping of schizophrenic psychoses or acute psychoses. Emil Kraepelin acknowledged the existence of psychotic-like symptoms in hysteria and contrasted them with dementia praecox.7 On the other hand, Eugene Bleuler took a different view, insisting that “hysterical psychosis” represented merely the occurrence of schizophrenia in a personality which was premorbidly hysterical.x As suggested by Sirois, the concept of hysterical psychosis was probably poorly accommodated by Freudian psychoanalysis or by descriptive psychiatry in the tradition of Kraepelin.g In 1964, Hollender and Hirsch defined hysterical psychosis using the following criteria: (1) sudden, dramatic onset, (2) temporal relationship to a profoundly upsetting event or circumstance, (3) the occurrence of hallucinations,
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delusions, depersonalization, or bizarre behavior in the absence of a major thought disorder or flattened affect (with affective volatility being more usual), (4) duration of one to three weeks with sudden, dramatic clearing and no residue, and (5) occurrence in hysterical personalities (predominantly women) or those with elements of this character type.‘O These authors endorsed the Freudian notion of “intrusion of unconscious material” as underlying the hysterical psychosis. Prinquet framed the hysterical psychosis in terms similar to Hollender and Hirsch.” He characterized the delusional picture further by the presence of mystical, religious, and sexual themes. The patients responded to low dose neuroleptics and returned to their premorbid state, but were subject to frequent and unforseen recurrences. The hysterical diathesis was seen in the suggestibiltendencies, sexual dysfunction, egocentrism, dramatizaity, “mythomaniacal” tion, and affective lability. Additionally, these patients were said to suffer diffuse and persistent anxiety and diverse symptomatology, including conversion symptoms, depressive state, twilight states, suicide attempts, and other behavioral disturbances. These patients, like those described by Hollender and Hirsch, never lost contact with reality. In 1969, Hollender and Hirsch revised their original findings delineating three different types of hysterical psychosis. I2 The first grouping, called “culturallywas developed, apparently, in response to the ansanctioned behavior” thropological work of Langness13 and subsumes such “culturally-bound” phenomena as latah, amok, negi negi, and whitiko psychosis. These phenomena were explained by them as institutionalized coping behaviors, created and maintained by the cultures involved. of psychotic behavior” is Their second category entitled “appropriation essentially a “conversion process taking the form of psychotic symptoms and behavior.” They contrast this with their third category, which they call “true psychosis,” and which is essentially the “surfacing of unconscious material” model, offered in their 1964 paper. Thus, in category two, “appropriation of psychotic behavior,” repression is reinforced, rather than disrupted, and the primary mechanism is strongly defensive. This suggestion is most interesting in light of the fact that hallucinations have also been reported to have arisen by a conversion mechanism in patients without more severe pathology, by Fitzgerald and Wells,14 McKegney,15 and Levinson.16 We might remark here, however, that Siomopoulus17 has recently challenged this conversion interpretation in patients with hysterical psychosis, preferring to stress instead a “linguistic shift” from the thought content frame of reference to that of sensory experience. Reports of hysterical psychotic-like syndromes have, by no means, been confined to the acute reactive forms discussed above. A number of chronic and subchronic forms have been discussed by anthropologists. Two culture-bound syndromes, latah and imu, have been observed to have chronic, deteriorating courses and Langness has suggested that chronicity may be a function of the social response to the illness.13 Examples of chronic psychotic-like behavior of a hysterical nature are possibly found in Western society as well. This is evidenced in the series of patients reported by Mallett and Gold.lR
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All of the patients reported by Mallett and Gold were women, and 10 of the 13 were classed as hysterical personalities. In marked contrast to Hollender and Hirsch’s definition, however, the onset in these cases was not acute, but was “insidious, with increasing depression, apathy, anergia, inability to care about work or personal relationships.” These patients also differed from the definition in that there was not necessarily any true resolution of their symptoms. These workers report that continued social deterioration was the outcome in 8 of their 13 patients, and that suicide was the result in 3 more. It should be noted that although these patients demonstrate a deteriorating course, the notion of underlying schizophrenia was rejected for valid clinical reasons, including absence of thought disorder and the presence of affective lability. One might also point out the lack of corroborative family history of schizophrenia in all but one of their 13 subjects. It is also interesting to note that these patients had little conviction of the reality of their hallucinations. Another very interesting point about these cases of Mallett and Gold is that the features of Briquet’s syndrome, or hysteria as defined by Guze, are present in many of the patients.‘” Seven of the cases of Mallett and Gold had histories of multiple somatic complaints leading to frequent visits with the general practitioner. Frigidity was a constant feature in all cases. All cases had hysterical personality traits and ten cases were diagnosed as such. (Hysterical personality occurs in two-thirds of patients with Briquet’s syndrome.)20 Moreover, a family history of male psychopathy was notable in several cases of Mallett and Gold, suggesting a similar genetic relationship as that hypothesized in Briquet’s syndrome.20 Another investigator, Dalle, discussed a group of cases given diagnoses of chronic hallucinatory psychosis, a diagnosis maintained distinct from schizophrenia by the French school.“* Dalle felt that a number of these cases (7%) with coexisting hysterical personality were qualitatively different from the others. These cases did not have the thought disturbances (incoherence, autism, and lack of judgement) characteristic of schizophrenia. Antecedent “conversion” symptoms coupled with apparent purposes of hallucinatory experiences lead Dalle to postulate a mechanism of “psychic conversion.” Interestingly, although Dalle reports only three cases in detail (two male), we perceive in this series of patients, as well, some of the features of Briquet’s syndrome including conversion symptoms, sexual dysfunction, and menstrual difficulties in the female. More recently, a paper by Spiegel and Fink provides additional evidence supporting the validity of the concept of a hysterical psychosis.” They report increased hypnotic suggestibility by Hypnotic Induction Profile in two cases diagnosed as hysterical psychoses. Moreover, they compare this heightened suggestibility to the reduced suggestibility reported in schizophrenic patients-an
interesting
contrast.
A DEFINITION
OF PSEUDOPSYCHOSIS
Having reviewed the development of the concept of hysterical psychosis, we will now endeavor to define, operationally, pseudopsychosis. We use the term pseudopsychosis to avoid the use of the ambiguous word hysterical and to distinguish our concept from true psychosis as we have discussed above. The
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Table
1. Operational
Definition for Pseudopsychosis
A. Predominant symptoms are delusions or hallucinations 6. Absence of derailment of thought and blunting of affect C. Psychologic factors are judged to be etioiogically involved in the symptoms as evidenced by: 1. A temporal relationship between psychologically meaningful environmental stimuli and initiation or exacerbation of the symptom 2. Symptoms enable the individual to avoid some activity that is noxious to him 3. Symptoms enable the individual to get support from the environment that otherwise might not be forthcoming, i.e., disability, solicitude D. At least two of the following that can not be explained on a medical basis during the patient’s life: 1. Visual hallucinations 2. Pains or bodily symptoms suggesting loss or alteration of function 3. Memory losses or amnesia 4. Homosexual preoccupation or involvement, or other problems of a sexual nature 5. Histrionic or antisocial personality E. Does not meet criteria for organic brain syndromes, schizophrenia, or affective disorder
definition is presented in Table 1. It follows the style of DSM-III and bears similarity to the operational criteria for the two somatoform disorders, conversion disorder and psychogenic pain disorder.-’ This definition of pseudopsychosis has several advantages over the widely cited Hollender and Hirsch definition. In addition to the explicit motivational criteria, the definition of pseudopsychosis does not limit itself to acute states, precipitating events are not required, and additional descriptors are provided to further define the syndrome. Furthermore, the diagnostic process is more explicit. THE DATA
Our survey of the literature reveals no systematic controlled study of cases which might be construed to represent pseudopsychotic behavior as we have discussed. There are, however, a number of anecdotal reports and brief case presentations. If our definition of pseudopsychosis is applied retrospectively to the cases reported in the literature (Table 2), most conform reasonably well. Our own cases meeting these criteria are reported in Table 3. Tables 2 and 3 reflect age, sex, type of hallucinations, and associated state in reported cases. Other common features are included under comments. The Literature
Cases
The average age for all patients (male and female) is 30.9 years (excluding one of Follin’s cases and Martin’s case, where no age is given). For the 40 women with reported ages, the average age is 29.8 years, and for the 7 men of stated age it is 39.6. Of 49 reported patients, 41 (83.7%) were female. Of the 39 cases where hallucinations were specified, 20 (51.3%) reported visual hallucinations and 21 (53.8%) reported auditory ones. Eleven patients (28.2%) reported both auditory and visual hallucinations. Ten patients were likely to have oneiroid states (20.4%), and 4 (8.2%) could have had parahypnic onset or exacerbation of illness. Of 18 papers, 4 (38.9%) report chronic courses in their patients, while 7 (38.9%) report subacute or periodic courses. Seven papers report that only acute courses were seen (38.9%). Of 18 papers, 9 (50%) report histories of
Table 2. Type of Hallucinations
Authors Follin et al.”
Hollender and HirschlO Mallet-t and Gold’Y
CsssS Age/Sex 55 M 30 F 48 M 29 M ?M
Hallucinations Visual Auditory
+ + +
+ +
+
+
I
13 cases, all females, mean age = 29 38 F 21 F
Levinsonl”
29 F
Cottraux et al.3R
37 F 42 F
Hirsch and Hollender’”
19 F 47 F
Dalle”’
44 M 65 F 40 M
Richman and White=
16 20 27 32
F F F F
?F
+
Comments Acute, subacute and chronic course, homosexual themes, conversion or somatization, memory loss
+ + +
+
Acute course Chronic course, somatization, sexual maladjustment
+
?+
+ +
+ +
+
+
?i
Acute course, sexual maladjustment, homosexual themes Chronic course Conversion symptoms, periodic and subacute courses
?+ +
Conversion pain, acute courses
+ +
Chronic courses, conversion symptoms, homosexual themes +
Acute courses
+
Unspecified + Unspecified
Acute course
+ +
MentzoQ
32 F 32 F
Unspecified Unspecified
Prinquet”
15F
+
Miller:‘”
30 M
+
SiroisY
29 F
+
i
Fitzgerald and Wells”
31 F
+
+
Spiegal and Fink”
15 M 31 F
Unspecified +
Cavenar et al.“’
21 23 24 30
Totals
Associated State Oneiroid Parahypnic
m+
33 F 21 F
F F F F
States Occurring in Cases of Hysterical Psychosis
+ +
45 F 24 F
McKegney’j
Mar-tin”*
and Superimposed
+
Acute and subacute courses, somatization Periodic and subacute course
+
Subacute course. amnesia, conversion symptoms Acute course, pseudo-homosexuality Acute course, somatization +
lntermittant course, amnesia, acute course, somatization I
?+
Acute courses
?+ ?i 20
Subacute course, somatization
21
10
4
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BISHOP AND HOLT
Table
3. Cases Seen by Authors Meeting the Operational CEA?S
Initial Diagnosis
Age/Sex
Hallucinations
Auditory
Associated
Visual
Hysterical psychosis
20 M
Hysterical psychosis
25 M
+
+
Chronic undifferentiated schizophrenia
28 M
+
+
Paranoid schizophrenia
12 F
+
+
Acute schizophrenia
43 F
+
Acute psychosis
44F
+
Acute schizophrenia
48F
Oneiroid
Definition of Pseudopsychosis State
Parahypnic
+
+
Comments
Acute course, antisocial personality
+
+
Probable Briquet’s chronic course, conversion symptoms
Chronic course, borderline personality, hysterical features, homosexual themes, conversion symptoms
+
+
Subacute course, phobias, hysterical personality features Acute course, recurrent episodes, antisocial personality, dissociation
+
Acute course following death of mother Acute course, recurrent episodes, conversion symptoms, hysterical personality features
somatization in their patients. Three of the papers report homosexual ideation in some of their patients, while one reports pseudohomosexuality. Sexual conflicts or maladjustments present in the vast majority of patients are not tabled. Personal
Cases
Of the seven cases that we have seen that meet the criteria in Table 1 for the the average age for all patients (male and diagnosis “pseudopsychosis,” female) is 31.4. For the three males, the average age was 24.3, and for females, 36.8. Of the seven patients, four (57.1%) were women and three (42.8%) were men. Of these seven patients, four had acute courses (57.1%) and of these four, two
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PSYCHOSIS
had recurrent episodes at later dates. One patient (14.3%) had a subacute course, and two patients (28.6%) a chronic one. Four patients (57.1%) reported auditory hallucinations and six reported visual ones (85.7%). Three patients (42.8%) reported both auditory and visual hallucinations. Three patients (42.9%) reported parahypnic hallucinations. and two (28.6%) experienced oneiroid states. Of these seven patients, two had hysterical personalities, two had borderline personalities with hysterical features, and two were antisocial personalities. NOSOLOGICAL
CONSIDERATIONS
In the United States, where little nosologic distinction is made between psychogenic and endogenous psychoses, or between acute or chronic psychoses. pseudopsychoses may often be diagnosed as a schizophrenic psychosis. This would seem to coincide with our own observations in Table 3 where initial diagnoses prior to our evaluation are reported, as well as with results found in numerous reports by others in our literature survey. It is also conceivable that the diagnosis of affective psychosis may claim a substantial number of these cases. In the new DSM-III categories, acute pseudopsychoses would be placed under the brief reactive psychoses on Axis I, while Axis II would indicate an underlying hysterical personality. Manifestations with a duration longer than one week would not be easily categorized. Subacute (less than 6 months) and chronic cases would be relegated to the atypical category and, therefore, would lose special designation. The special category of brief reactive psychosis is an improvement over the lack of designation that existed before, but does not identify the inauthenticity of many brief states or accommodate variability in the course of many pseudopsychoses reported in the literature. PSEUDOPSYCHOSIS
AND REACTIVE
PSYCHOSIS
Interestingly, many clinicians in the United States equate the term hysterical psychosis with the term reactive psychosis, as, for example, Pincus and Tucker do in their discussion of the differential diagnosis of schizophrenia.z3 Hollender and Hirsch also recognized a possible relationship to the reactive psychoses in referencing the work of Astrup et al.24 Regarding this issue, there would seem to be merit in maintaining a distinction between psychogenic or reactive psychoses in terms of the hypothesized nature of the symptoms. This conceptual distinction would consider the symptoms, in the former category, as manifestations of dissolution or disequilibrium of mental function, as conceptualized by Eyl” and, in the latter category, as motivationally determined phenomena initiated and maintained by psychosocial factors. While such a distinction may be difficult to establish in cases of acute onset following meaningful environmental events, we feel that it might serve as a diagnostic principle that could aid in delineating more homogeneous groups of patients. This issue of true psychosis versus pseudopsychosis was approached by Hirsch and Hollender.‘” Concordant with the conceptual distinctions of this paper, they claimed one of the three types of hysterical psychosis as being
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“true psychosis.” This group of psychoses probably overlaps with the Scandanavian concept of psychogenic psychosis. Whether hysterical psychoses of this type should be delimited from the psychogenic psychoses is debatable. Even if the psychogenic psychoses are valid entities, the so-called hysterical psychosis could be none other than the concurrence of a psychogenic psychosis and a “hysterical” personality. Striimgren found no relationship, however, between personality and the form of reactive psychoses.26 What remains of Hirsch and Hollender’s types of hysterical psychoses are the “culture-bound” syndromes and “conversion” psychoses with appropriation of psychotic behavior. These latter groupings would be included in our concept of pseudopsychosis. Although our usage of the term pseudopsychosis is conceptually distinct from psychogenic psychosis, it probably merges with the Ganser pseudodementia much as “conversion hysteria” often shades into malingering in actual clinical practice. Ganser referred to his cases, interestingly enough, as “hysterical twilight states.” The obvious goals in the Ganser situation are avoidance of punishment and absolution from responsibility for one’s actions. Although Ganse? did not feel that malingering played a major part in the clinical picture, it is difficult to see why it would not. When one examines the data from the case reports of hysterical psychosis in the literature, a possible relationship to the somatoform disorders emerges. One can analogize the relationship of acute pseudopsychoses to chronic pseudopsychoses with that of conversion disorder to Briquet’s syndrome. (The terms “acute” and “chronic” hysteria have been used.Y8 Conversion symptoms, as defined by Guze,ls are often transient phenomena which resolve without sequelae in a number of patients followed up five years later.2g These cases would correspond to the acute forms of pseudopsychosis, such as those defined descriptively by Hollender and Hirsch.12 With regard to “chronic hysteria,” Briquet’s syndrome is, of course, the operationally defined somatoform disorder that would correspond to the chronic pseudopsychosis such as that described by Mallett and Gold’” and Dalle.21 As we have discussed, both acute and chronic forms of pseudopsychosis are often accompanied by conversion symptoms and other characteristics held in common with their possible somatic counterparts. DISCUSSION
Temoshok and Attkisson30 have ordered hysterical phenomena with regard to course as we discussed above. These authors felt that hysterical phenomena align themselves more naturally along a chronic-acute axis than a psychoticneurotic axis. We concur with this conceptualization because we believe that the phenomena under question are not true psychoses in the usual sense of the word, as elaborated earlier. The usual dichotomization of mind and body seems to naturally lead to a psychotic-neurotic categorization and its implications when dealing with pseudosymptoms. We feel that the choice of symptoms in either the somatic or mental sphere probably depends more on social factors rather than on any intrinsic abnormality of the brain. That is, patients with pseudopsychotic symptoms probably share in common similar pathogenic
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159
mechanisms found in patients manifesting somatoform disorders. (See Pilowsky’s classification of abnormal illness behavior.31) The concept of pseudopsychosis that we have discussed would seem to deserve further verification for several reasons. First, the treatments for various major psychoses are obviously inappropriate and possibly harmful for individuals who do not have alteration of brain functioning. Second, more of society’s disenfranchized persons are likely to shift coping strategies that use illness behavior from the realm of the somatic symptom to that of the psychic symptom, because there is less exactitude in psychiatric diagnosis, and because society is less naive about bodily functioning and illness today that it has ever been. Third, the widespread availability of mental health services and decreased stigmatization of mental illness will tend to encourage those disenfranchized individuals of society to enlist the support of public services by way of simulated psychotic illness, much in the same manner that patients with conversion symptoms have done within the sanctions of the sick role. Although the lack of systematic controlled studies of pseudopsychotic behavior precludes definite conclusions, our perusal of the literature and our own case observations yield some interesting and testable hypotheses. Two hypotheses arising out of this preliminary data relate to the suggested accentuation of symptomatology during the parahypnic phases of wakefulness, and relate to the relatively higher frequency of visual hallucinations. The common visual nature of the hallucinations and their accentuation in the parahypnic phases of wakefulness are particularly notable in our survey. Ey et al.“” made this latter point in discussing acute delusional psychoses. Although we have not seen this explicitly stated, onset of the hysterical psychosis in a parahypnic phase would seem to be present in several case reports,‘(‘,‘4 -Ii~~~~ ‘lpincluding three of our own. It has been stated that hypnogogic hallucinations are seen frequently in “hysterical patients.““4 Visual hallucinations, whether hypnogogic or diurnal, are said to be more typical of hysterical patients”” and they are seen quite commonly in the cases listed in Tables 2 and 3. Visual hallucinations are seen in 51% of the cases reported. Oneiroid and parahypnic phenomena may be underrepresented in these cases. As we have discussed earlier, pseudopsychotic behavior is probably similar to somatoform behavior. The association of hysterical psychoses with conversion symptoms or somatization is frequent in our cases and those of the ~~~~~~~~~~~~.9.li,~~,lI,l7.lX,~l.~.~~~~ This association should be studied further on well-defined samples of patients. Although the literature invariably links the hysterical psychosis to the hysterical personality, this may not be necessarily so. In our series we found hysterical personality features in four of seven cases-certainly not an unfailing observation. Quite interestingly, we found two antisocial personalities. In one case we could make no clear decision about personality type. It is entirely possible that, as with conversion reactions. there is no obligatory relationship between pseudopsychoses and hysterical personality. Conversion symptoms are frequent in individuals diagnosed as antisocial personalities,“7 and it is not surprising that two antisocial personalities presented psychotic-like behavior. Briquet’s syndrome (hysteria) apparently shares a genetic etiology with the antisocial personality”’ and may enter the
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picture as we have seen in Case 2. While the precise nature of the relationship between these various clinical syndromes remains to be clarified, it is possible to utilize a clinical triad of psychotic-like behavior, somatization, and histrionic or antisocial personality as a red flag for pseudopsychosis. In this paper we have tried to stimulate interest and to raise awareness of some patients who may be simulating psychotic illness. Much remains to be learned about these patients in terms of scientific explanation. Perhaps, if we define them more precisely we may begin to identify those intrinsic and extrinsic factors interacting to produce pseudopsychotic phenomena. REFERENCES 1. Slater E: The diagnosis of “hysteria.” Br Med J 1:1395-1399, 1965 2. Rosenhan DL: On being sane in insane places. Science 180:250-258, 1973 3. Manschreck TC: Acute psychosis: Attempts at clarification, in Manschreck TC, Kleinman AM (eds): Renewal in Psychiatry. Washington, Hemisphere Publishing, 1977, pp. 45-96. 4. Task Force on Nomenclature and Statistics. DSM III draft. Washington, DC, American Psychiatric Association, 1978 5. Follin S, Chazaud J, Pilon L: Cas cliniques de psychoses hysteriques. Evolution Psychiatrique, 261257-286, 1961 6. Mentzos S: Zur psychodynamik der sogenannten “hysterischen” psychosen. Nervenart 44:285-291. 1973 7. Kraepelin S: Dementia Praecox and Paraphrenia. Huntington, New York, Krieger, 1978. pp. 270-272 8. Bleuler E: Dementia Praecox and the Group of Schizophrenias. New York, International Universities Press. 1950, p. 289 9. Sirosis F: La psychose hysterique. Psychiat J U Ottawa 2:72-77, 1977 10. Hollender MH, Hirsch SJ: Hysterical psychosis. Am J Psychiatry 120:1066-1074, 1964 11. Prinquet G: A propos d’un cas de psychose hysterique. Nouv Presse Med 6:441-443, 1977 12. Hirsch SJ, Hollender MH: Hysterical psychosis: Clarification of the concept. Am J Psychiatry 125909-915, 1969 13. Langness LL: Hysterical psychosis: the cross-cultural evidence. Am J Psychiatry 124:143-152, 1967 14. Fitzgerald BA, Wells CE: Hallucinations as conversion reaction. Dis Net-v Syst 38:381383, 1977 15. McKegney FP: Auditory hallucination as
a conversion symptom. Compr Psychiatry 8:80-89. 1967 16. Levinson H: Auditory hallucinations in a case of hysteria. Br J Psychiatry 112:19-26, 1966 17. Siomopoulus V: Hysterical psychosis: Psychopathological aspects. Br J Med Psycho1 44:95-100, 1971 18. Mallett BL, Gold S: A pseudoschizophrenic hysteria syndrome. Br J Med Psycho1 37159-70, 1964 19. Guze SB: The validity and significance of the clinical diagnosis of hysteria (Briquet’s syndrome). Am J Psychiatry 132:138-141, 1975 20. Cloninger CR: The link between hysteria and sociopathy: An integrative model of pathogenesis based on clinical. genetic and neurophysiological observations, in Akiskel HS Weeb WL teds): Psychiatric Diagnosis: Exploration of Biological Predicators. New York. Spectrum, 1978, pp. 270-272 21. Dalle B: Syndrome hallucinatoire chronique et hysteric. Evolution psychiatrique 34:339-359, 1969 22. Spiegel D, Fink R: Hysterical psychosis and hypnotizability. Am J Psychiatry 136:777781, 1979 23. Pincus JH, Tucker GJ: Behavioral Neurology. New York. Oxford University Press, 1978 24. Astrup C, Fossum A, Homboe R: Prognosis in functional psychoses. Springfield, Ill. Charles C Thomas, 1962, pp. 11l-161 25. Ey H: Outline of an organo-dynamic conception of the structure, nosography, and pathogenesis of mental disease, in Natanson M (ed): Psychiatry and Philosophy, New York, Springer-Verlag, 1969 26. StrSmgren E: Psychogenic psychoses, in Hirsch SR, Shephard M (eds): Themes and Variations in European Psychiatry. Charlottesville, University of Virginia Press. 1974, pp. 97-117
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