‘Introduction’ to ‘Episodic Psychoses’,by Erik Strömgren (1940)

Introduction

This anniversary Classic Text, on ‘Episodic Psychoses’ (Strömgren, 1940), is but one gem taken from the many excellent and some epoch-making works of the famous Danish psychiatrist, Erik Strömgren (Schioldann and Sand Strömgren, 1996), not previously translated into a major language, of high relevance in the history of psychiatry and classic psychopathology, but no less relevant in today’s psychiatry, nosography and nosology.

The author

Erik Strömgren was born in Copenhagen in 1909 and died in 1993 from pancreatic cancer. Among his obituaries, one was published in this journal in the same year (Schioldann, 1993a). In the words of Norman Sartorius (Schioldann and Sand Strömgren, 1996), who knew him well, personally and professionally, he ‘performed outstandingly important research which demonstrated the nature of mental illness and made psychiatry a respectable part of medicine’. His humanism and his concern for the plight of the mentally ill were legendary. Strömgren was a founding father of psychiatric epidemiology and genetics, renowned diagnostician and classifier of mental illnesses, world-class researcher in several fields, teacher, adviser and mentor to many, at home and abroad (Gottesman and Bertelsen, 1996). With his ‘ideology-free’ views he became an important mediator in the rehabilitation of psychiatric epidemiology after World War II, when genetics had become an anathema. He was also called upon by the then West German government to act as an adviser on psychiatry and to assist in the rehabilitation of German psychiatry into international psychiatry. He made important contributions to Wimmer’s concept, psychogenic psychoses, and fought tirelessly for its acceptance in world psychiatry (Schioldann, 1993b, 2003, 2011).

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Figure 1.

Erik Strömgren (1909–93); photo received from his wife, the late Dr Lizzie Sand Strömgren.

Regrettaby, Strömgren declined to write his biography, but he fortunately agreed to interviews with Michael Shepherd (Strömgren, 1982) and Mogens Schou (Schioldann, 2002). In his ‘Annual Eliot Slater Lecture’ in 1986, he provided an indispensable overview of the recent history of European psychiatry and some of its personalities, and this was published posthumously, in slightly adapted form (Strömgren, 1994a), on the initiative of Irving Gottesman and Aksel Bertelsen (Bertelsen, 1999).

Strömgren was one of world psychiatry’s greatest figures in the twentieth century. He has earned himself a place in the history of psychiatry.

The text

As Strömgren put it, episodic psychoses are not a precise unequivocal concept and not ‘even’ to be found in any of the ‘customary’ psychiatric classifications. The crux of the matter was the delimitation and classification of a group or groups of mental illnesses which are characterized by a benign course and outcome, the distinctive hallmark of which is a tendency to recur in episodic (epeisodion = incident) fashion, as opposed to illnesses occurring in periodical (periodos = cycle) fashion, i.e. manic-depressive disorder, or as phases (phasis = ‘in a state of change’), or episodes in schizophrenia. According to Strömgren, a number of mental illnesses exist whose genesis and course, despite possible symptomatological similarity, did not allow for their grouping under any Kraepelinian categories of psychoses. However, a scientific classification was not the only hurdle. A pressing issue was also that of their therapy. Strömgren’s aim, therefore, was to review the whole field of episodic disorders, both clinically and theoretically, that is, their nosography and nosology.

In 1940, in five lectures to his colleagues in the Psychiatric Department, Rigshospitalet, Copenhagen, Strömgren presented the results of his scrutiny of the case histories of patients who in the previous four years had been admitted to the Department for ‘episodic psychoses’, and his studies of the literature. The lectures were published in the same year, entitled Episodiske Psykoser (Strömgren, 1940), under the headings: (1) ‘Introduction’, (2) ‘Motility psychoses’, (3) ‘Borderline psychoses of the endogenous psychoses’, (4) ‘Episodic paranoid psychoses. - General views concerning the genesis of paranoid syndromes’, (5) ‘Other episodic psychoses. - Grouping of the episodic psychoses’. Finally, a table of episodic psychoses was attached, showing their relations, ‘constitutional’ and ‘symptomatological’, to the major Kraepelin psychoses and epilepsy, namely ‘exogenous’ for both dimensions, subdivided into ‘psychogenic’ and ‘somatogenic’.

Strömgren’s exposition is excellent, eloquent, comprehensive and concise, illustrating his encyclopaedic knowledge and sovereign understanding of classical psychopathology. Each of the five lectures would, individually, deserve publication as a Classic Text in History of Psychiatry. However, as a choice had to be made, I found the natural choice to be that of the ‘Introduction’.

The construct

The so-called theory of degeneration (dégénérescence, Entartung) was formulated by Morel in the 1850s (Morel, 1857) and systematized and fine-tuned in the 1880s and 1890s by Magnan (1893; Magnan and Legrain, 1895) and his pupils, Saury (1886) and Legrain (1886), under the terms délires des dégénérés, délire d’emblée, bouffées délirantes (aiguës), bouffée délirante polymorphe des dégénérés. These conditions were described as occurring in individuals of fragile constitution, terrain préparé (préformé), in conformity with Magnan’s concept (Schioldann, 2003, 2011; see also Ey, Bernard and Brisset, 1974; Perris, 1995). Wimmer (1902) stated that although a number of authors (e.g. Prichard, Morel, Campagne, Griesinger, Schüle) had described the vast field of mental degeneration, it was left to Magnan to draw together the ‘proteus-like’ degeneracy conditions into simple and clear notions. Magnan dealt with: (1) the permanent mental state, état mental (‘déséquilibration’), (2) syndromes épisodiques, (3) culminating in insanity proper, état délirant. There would no precipitating event or at the most minimal identifiable stress.

Wimmer had devoted his doctoral thesis (Evolutiv Paranoia, 1902) to a study of Magnan’s délires des dégénérés. With reference to the aforementioned authors, he emphasized that individuals with these conditions are characterized from their earliest years by a special psychic degeneration state, which he termed paranoigenic degeneration (temperament), and which ‘in nuce contains all the elements for the ensuing paranoia’. Next, through an evolution, i.e. a proliferation [‘over-flowering’] of all underlying psychic abnormalities, congruently with the strength of the predisposition and the nature of the ‘environment’, ‘mild paranoia forms’ (Friedmann, 1905), or ‘abortive paranoia’ (Gaupp, 1910), or acute explosive attacks of paranoid states (Magnan’s ‘bouffées délirantes’) (Wimmer, 1929), are manifested. Premonitory symptoms could occur in the form of depression, exaltation or confusion, and the course of the illness (degeneration psychosis) could be interrupted by remissions or intermissions. Wimmer equated ‘the various forms of psychogenic (affective, paranoigenic) diathesis’ with Magnan’s degenerative states (Wimmer, 1918). More generally, according to Wimmer, Magnan’s teachings of the délires des dégénérés illustrated many of the principal features of the psychogenic illness pictures.

Strömgren (1940) emphasized that Magnan’s syndromes encompassed both psychotic reactions and certain neurotic exacerbations, and as far as Magnan’s psychosis types were concerned, they were predominantly psychogenic psychoses in psychopaths. Strömgren characterized the acute paranoid reaction, designated délire d’emblée, as a particularly well-known syndrome. He was undoubtedly referring to Kraepelin’s view (1915: 1768–1769) that ‘the delusion formations of the degenerate [the ‘bouffées délirantes’ of the French] are, as far as it is known today, commonly of psychogenic origin and are connected to a definite tangible precipitant [Anlass]’, and to Kleist, who in his Episodische Dämmerzustände (Kleist, 1926; see also Bunse, 1918) spoke of ‘reaktiven, psychogenen Erkrankungen der Psychopathen’. Kleist also held the view that ‘die rasch aufschiessenden und meist ebenso rasch wieder abklingenden Wahnpsychosen (Délire d’emblée) sind […] reaktive Wahnbildungen’. Birnbaum (1908) had drawn attention to the important association that, in his opinion, existed between degeneration psychoses and ‘the psychogenic illness forms, and thus in a broader sense related to hysteria’. Færgeman (1945, 1963) reiterated this view that ‘degenerative psychoses are, to a certain extent, identical with psychogenic psychoses’. Importantly, according to Strömgren, Magnan’s concept comprised ‘a large part’ of the ‘episodic psychoses’ (Strömgren 1940, 1972, 1992).

Around the age of 15, Strömgren read Freud’s Über Psychoanalyse (1910) – and shortly afterwards he started reading Bleuler’s Lehrbuch der Psychiatrie (1916). During his last year as a medical student – he graduated at the age of 24, in 1933 – Strömgren spent six months in a sanatorium due to a lung infection. Despite his illness he remained an avid reader of psychiatric literature. He performed Rorschach tests on his fellow patients in order to obtain an impression of the personality structure of mentally normal individuals. Further, in conversations with them he explored the existence of important features of their ‘self-image’ of which they were usually unaware. At this time Strömgren would not only have attended Wimmer’s lectures at the university but also have read his Evolutive paranoia (1902) and his magisterial Psykogene Sindssygdomsformer (1916), and most likely have had discussions with him on psychiatric matters, including episodic psychotic conditions. At this stage Strömgren felt inspired/indebted to Wimmer, as evidenced by the fact that in 1932, when still a medical student, he contributed an article on ‘Constitution type and the senile arc’ to the ‘Festskrift’ on the occasion of Wimmer’s sixtieth anniversary (Strömgren, 1932), incidentally his first publication. Strömgren worked under Wimmer at the Rigshospitalet in Copenhagen from 1935 until 1937, when Wimmer died. As already mentioned, the empirical basis for Strömgren’s Episodiske Psykoser consisted of case histories of patients suffering from these conditions and admitted during the preceding four years. Therefore it is likely that he had discussed at least some of them with Wimmer, whom he considered to be ‘the most learned psychiatrist of his time or perhaps of all times’, praising his ‘immense erudition’ and ‘clinical peerless acumen’ (Strömgren, personal communication, 11.2.1993).

Subsequently, Strömgren seemingly abandoned the term ‘episodic psychoses’, replacing it with the term ‘psychogenic psychoses’, and later, with some reluctance, he also used its substituting term ‘reactive psychosis’. Strömgren’s ‘Bio-bibliography’ (Schioldann and Sand Strömgren, 1996) contains numerous references in support of this view. ¹ ‘Reactive psychoses’ had been included in the Norwegian Psychiatric Classification of 1963 (Ödegaard, 1968), a move that was much welcomed by Færgeman (1964: 124–34), who considered the term psychogenic psychosis to be ‘semantically ambiguous’. Strömgren (1980, 1987) expressed a dissenting view, remarking (Strömgren, 1987, Schioldann, 2003) how Norwegian psychiatry had used the term ‘constitutional psychoses’, which was identical to psychogenic psychoses in Danish psychiatry. The Norwegian use of the concept was a sequel to ‘the old French degeneration theory’, the bouffées délirantes of the French school, and when the former became obsolete, so did the term ‘constitutional psychoses’. It is thought-provoking that French psychiatry in its classification of mental diseases of 1968 (INSERM: 04.1) had introduced the hybrid term, bouffée délirante réactionelle. In the words of Strömgren (1987), Scandinavian psychiatry had found a compromise in the term ‘reactive psychoses’ which was in accordance with the terminology in ICD-8, and in 1977 it had an entry in DSM-III, designated ‘brief reactive psychosis’, a term which also evoked Strömgren’s disapproval (Strömgren, 1992, 1994a, 1994b; see also Schioldann, 2003). He reiterated his long-held view that in French psychiatry the psychogenic psychoses can be found under the Magnanian categories and terms (Strömgren, 1992). Sirère (1999) very appropriately now entered the dispute with the rhetorical question: ‘si le concept de réaction (psychose réactionelle brève du DSM, psychose psychogénique des Scandinaves) n’en est pas un avatar’ of Morel’s obsolete doctrine of degeneration, and hence of Magnan’s bouffée délirante; the question goes to the very core of this vexed issue, a bone of contention in international psychiatry for many decades and an obstacle in achieving consensus in international psychiatric classification (Schioldann, 2003). Finally, it must be concluded that the term ‘episodic psychosis’ is an intermediate link between the degeneration psychoses, now an obsolete term, and the psychogenic psychoses.