LETTERS
an autoscopic type, first described by Cristodoulou (2), in which the patient recognizes physically identical doubles of himself in persons around him. We present another variant of the syndrome of subjective doubles with an unusual disturbance in experiencing time.
Mr. because
A, a 19-year-old of disturbing
student, auditory
was admitted hallucinations
to a clinic and suicidal
ideation. On admission he showed blunted affect and reported voices commenting on his behavior, audible thoughts, and delusions of thought broadcasting and thought withdrawal-experiences of influence, yet without manifest behavioral aberrations. The next day he became nervous and agitated. On questioning he described the impression that he had already been on this ward. He was puzzled and irritated because he was conscious of the fact that this could not be true. He reported an overwhelming sense of familiarity with his surroundings, although he could not cite any concrete similarities to previous experiences. He felt that the individuals on the ward-patients and male personnel-were also familiar and that they had something in common with him and with one another which he could not explain. Later on he lost all sense of reality and expressed the conviction that all of these men were in fact the same person (namely, himself) and that their different appearances were because of their different ages. There was the Mr. A of yesterday, the Mr. A of tomorrow, and the Mr. A of the day after tomorrow. All of these were his own person at different times; the oldest was going to die, and then a part of himself would be dead. Findings from a neurological examination, routine laboratory investigation, CSF, brain scan, EEG, and a battery of psychological tests were all normal. We diagnosed pananoid schizophrenia (DSM-III) and treated Mr. A with ncuroleptics. After improvement and discharge he tried unsuccessfully to continue his studies. He was readmitted with a depressive syndrome after the suicide of his father a few months later. He was still taking the neuroleptics prescnibed after the first discharge. On the second admission neither first-rank symptoms nor paranoid misidentifications could be detected.
This case differs from the known variants of the syndrome of subjective doubles in that 1) the doubles were not just believed in, as is true in Capgras’ type, and 2) there was no physical identification with them, as there is in Cristodoulou’s type. Otherwise, there are striking similarities to the autoscopic phenomena and especially to the deuteroscopic type, namely, the experience of a psychological but not a physical duplication of one’s real self (3). Benson (4) postulated that there arc common factors between the Capgras and autoscopic phenomena. We think that the feelings of d#{233} ja vu, or d#{233} ja vecu, that initiated the symptoms in our patient and in Cnistodoulou’s original patient are identical to the feeling of “belonging” considered by Damas Mona et al. (3) to be the most significant feature of autoscopy. It seems that feelings of an “ultimate familiarity” constitute a cardinal common factor in the development of these phenomena and could offer, beyond the fanciful terminology, the conceptual framework for a more thorough understanding and a more simple classification.
AmJPsychiatry
148:3,
March
1991
TO THE
EDITOR
REFERENCES 1
. Singer
SF: Capgras syndrome: the delusion of substitution. J Clin Psychiatry 1987; 48:147-150 2. Cristodoulou GN: Syndrome of subjective doubles. Am J Psychiatry 1978; 135:249-251 3. Damas Mora JMR, Jenner FA, Eacott SE: On heautoscopy or the phenomenon of the double: case presentation and review of the literature. Br J Med Psychol 1980; 53:75-83 4. Benson Ri: Capgras’ syndrome. Am J Psychiatry 1983; 140: 969-978 D. VARTZOPOULOS, I. VARTZOPOULOS, Thessaloniki,
Dissociation
in Endogenous
M.D. M.D. Greece
Psychosis
SIR: Dissociation phenomena were major areas of clinical investigation during the time of Janet (1). Subsequently, there has been a decline of interest in these clinical syndromes, although there has been no evidence to suggest that the incidence of the phenomena has in any way diminished since that time (2). Conversion symptoms involving the sensonimotor system are frequently seen in patients with somatic diseases (3) and psychiatric disorders (4). Shalev and Munitz (5) reported a case in which conversion was associated with paranoid psychosis. The combination of dissociation phenomena and endogenous psychosis is not frequently reported in the literature. We report two cases from north India in which patients with endogenous psychosis also had dissociation symptoms. Ms. A, a 52-year-old married woman, had a diagnosis of bipolar affective disorder according to the DSM-III-R criteria. At the age of 45 years she had had her first attack of endogenous depression. This episode was characterized by sadness, weeping spells, suicidal ideas, insomnia, negative ideas, and psychomotor retardation. Since then she had been having one or two attacks of mania and depression every year. The manic attacks were characterized by increased psychomotor activity, inappropriate euphoria, and insomnia. She did not respond to lithium prophylaxis. She had been hospitalized three times, once for depressive illness and twice for manic excitement. After recovery from the third attack of depression, Ms. A began to have episodes of unconsciousness during which she would become unresponsive; these lasted for a few minutes to a few hours. Twice during these episodes, EEGs failed to show seizure activity. The episodes could be induced by suggestion, and she had partial amnesia for events during them. The episodes always occurred in periods of severe depression; she never experienced them during manic psychosis and symptom-free periods. Mr. B, a 23-year-old unmarried man, was an outpatient who had a diagnosis of schizophrenia according to the DSM-III-R criteria. His first attack of schizophrenia had occurred when he was 16 years old. His illness was charactenized by psychomotor excitement, violence, inappropriate affect, and suspiciousness. The symptoms did not remit after the first attack, and although he had been given regular maintenance injections of fluphenazine decanoate, he had been having one or two acute exacerbations every year. After improving from the second attack of the illness,
395
LETTERS
TO THE
EDITOR
he started to have episodes of unconsciousness lasting from 15 to 30 minutes, during which he would close his eyes and clench his teeth. He remained responsive to deep and painful stimuli but did not respond to verbal stimuli. He experienced three to five of these episodes a week, and they could be induced by suggestion. Twice during such episodes, EEGs did not show evidence of seizure activity. Both of these cases were characterized by concurrent endogenous psychosis and dissociation. The presence of dissociation in these patients could not be correlated with specific life events that were meaningful to them. Could the episodes of dissociation have been the result of release of psychotic anxiety? It is interesting to note that for each of these patients there was a time lag following the first episode of psychosis before the dissociation symptoms appeared. It is possible that in chronic patients, tolerance of stress becomes much less, and in these patients dissociation was precipitated by very minor stresses that could not be elicited by our repeated interrogation. This report clearly shows that neurotic phenomena are not only the domain of neurotic patients but that psychotic patients can also develop these symptoms.
REFERENCES 1. Janet P: The Major Symptoms of Hysteria. New York, Macmillan, 1987 2. Nemiah JC: Dissociative disorders (hysterical neurosis, dissociative type), in Comprehensive Textbook of Psychiatry, 4th ed, vol 1. Edited by Kaplan HI, Sadock BJ. Baltimore, Williams & Wilkins, 1985 3. Chaturvedi 5K, Upadhyaya MP, Rao P: Somatic complaints in a community clinic. Indian J Psychiatry 1968; 30:369-374 4. Gautam SK, Kapur RL: Psychiatric patients with somatic complaints. Indian J Psychiatry 1977; 19:75-80 S. Shalev A, Munitz H: Conversion without hysteria: a case report and review ofthe literature. BrJ Psychiatry 1986; 148:198-203 RAJEEV GUPTA, L.S. CHAWLA, Ludhiana,
Organic
Mental
Disorders
and
M.D. M.D. India
dens of delirium, dementia, and amnestic disorder within the overall rubric of cognitive impairment disorders. The second goal is to replace the term “organic” with a term that is more precise and less likely to perpetuate the false implication that the “nononganic” disorders lack a significant biological component in their etiology. We believe that the term “secondary,” as in “secondary mood disonden,” more cleanly conveys the DSM-III-R and lCD-i 0 constructs, namely, a disturbance of mood that is judged to be secondary to a nonpsychiatnic medical disorder. Dr. Lipowski believes that any confusion in the meaning of the term “organic” can be solved by the ICD-10 statement that the term merely means “that the syndrome so classified can be attributed to an independently diagnosable cerebral or systemic disease.” We doubt that this or any other attempt to redefine “organic” will succeed in overcoming the unfontunate historical baggage that the term has accrued. In fact, the wording of the lCD-i 0 statement is equivalent to the way in which we are proposing that the term “secondary” be used. The introduction of any change in psychiatric classification and terminology has the potential for creating shortterm confusion, since users have to learn new concepts. In this case, we feel that the long-term benefits in clarity and in improved differential diagnosis, on balance, justify what we regard as an important step forward in our nosology. With several of our colleagues on the Task Force on DSM-IV and the Work Group on Organic Mental Disorders, we are currently preparing a paper that makes a complete presentation of the proposal, including a historical review, as well as nesponses to critiques of the proposal.
REFERENCES 1. Lipowski ZJ: Organic mental disorders and DSM-IV (letter). Am J Psychiatry 1990; 147:947 2. Lipowsky ZJ: Is “organic” obsolete? (editorial). Psychosomatics 1990; 31:342-344 3. Spitzer RL, Williams JBW, First MB, et al: A proposal for DSMIV: solving the “organic/nonorganic problem” (editorial). J Neuropsychiatry Clin Neurosciences 1989; 1:126-127 4. Popkin MK, Tucker G, Caine E, et al: The fate of organic mental disorders in DSM-IV: a progress report. Psychosomatics 1989; 30:438-441 ROBERT L. SPITZER, MICHAEL FIRST, GARY TUCKER,
DSM-IV
New
SIR: In this journal (1) and elsewhere (2), Z.J. Lipowski, M.D., has characterized a proposal to eliminate the category of organic mental disorders in DSM-IV as “idiosyncratic” and likely to “create confusion” and “impede communication.” This proposal was originally formulated by Robert L. Spitzcr, Janet B.W. Williams, Michael B. First, and Kenneth S. Kendler (3) and arose in response to concerns among work group members and experts in the field that the onganic/ nonorganic distinction had become anachronistic. The final proposal, presented by the DSM-IV Work Group on Organic Mental Disorders (4), has two main goals. The first is to facilitate differential diagnosis by grouping phenomenologically similar syndromes on disorders in the same major diagnostic class. Thus, the clinician, in determining the differential diagnosis of depressed mood, would find within the class of mood disorders what in DSM-III and DSM-III-R were called organic mood disorder and drug-induced mood disorders. A natural consequence of this approach is to retain together the traditional (pre-DSM-III) organic mental disor-
396
Dr.
Lipowski
York,
M.D. M.D. M.D. N.Y.
Replies
SIR: Dr. Spitzen and associates object to my critique of the proposed abolition of the category of organic mental disonders in DSM-IV, yet they fail to provide any convincing rcasons in support of this proposal. A term means no more and no less than its definition specifies and this applies to the term “organic” in the present context. I have just received the 1990 draft of chapter 5 of ICD-10, which contains a separate section called “Organic, Including Symptomatic, Mental Disorders.” It is introduced by a statement that “this section comprises a range of mental disorders grouped together on the basis of their having in common a demonstrable actiology in cerebral disease, brain injury, or other insult leading to cerebral dysfunction” (p. 30). It is further stated that “the term ‘organic’ means no more and no less than that the syndrome so classified can be attributed to an independently
Am
J
Psychiatry
1 48:3,
March
1991
an autoscopic type, first described by Cristodoulou (2), in which the patient recognizes physically identical doubles of himself in persons around him. We present another variant of the syndrome of subjective doubles with an unusual disturbance in experiencing time.
Mr. because
A, a 19-year-old of disturbing
student, auditory
was admitted hallucinations
to a clinic and suicidal
ideation. On admission he showed blunted affect and reported voices commenting on his behavior, audible thoughts, and delusions of thought broadcasting and thought withdrawal-experiences of influence, yet without manifest behavioral aberrations. The next day he became nervous and agitated. On questioning he described the impression that he had already been on this ward. He was puzzled and irritated because he was conscious of the fact that this could not be true. He reported an overwhelming sense of familiarity with his surroundings, although he could not cite any concrete similarities to previous experiences. He felt that the individuals on the ward-patients and male personnel-were also familiar and that they had something in common with him and with one another which he could not explain. Later on he lost all sense of reality and expressed the conviction that all of these men were in fact the same person (namely, himself) and that their different appearances were because of their different ages. There was the Mr. A of yesterday, the Mr. A of tomorrow, and the Mr. A of the day after tomorrow. All of these were his own person at different times; the oldest was going to die, and then a part of himself would be dead. Findings from a neurological examination, routine laboratory investigation, CSF, brain scan, EEG, and a battery of psychological tests were all normal. We diagnosed pananoid schizophrenia (DSM-III) and treated Mr. A with ncuroleptics. After improvement and discharge he tried unsuccessfully to continue his studies. He was readmitted with a depressive syndrome after the suicide of his father a few months later. He was still taking the neuroleptics prescnibed after the first discharge. On the second admission neither first-rank symptoms nor paranoid misidentifications could be detected.
This case differs from the known variants of the syndrome of subjective doubles in that 1) the doubles were not just believed in, as is true in Capgras’ type, and 2) there was no physical identification with them, as there is in Cristodoulou’s type. Otherwise, there are striking similarities to the autoscopic phenomena and especially to the deuteroscopic type, namely, the experience of a psychological but not a physical duplication of one’s real self (3). Benson (4) postulated that there arc common factors between the Capgras and autoscopic phenomena. We think that the feelings of d#{233} ja vu, or d#{233} ja vecu, that initiated the symptoms in our patient and in Cnistodoulou’s original patient are identical to the feeling of “belonging” considered by Damas Mona et al. (3) to be the most significant feature of autoscopy. It seems that feelings of an “ultimate familiarity” constitute a cardinal common factor in the development of these phenomena and could offer, beyond the fanciful terminology, the conceptual framework for a more thorough understanding and a more simple classification.
AmJPsychiatry
148:3,
March
1991
TO THE
EDITOR
REFERENCES 1
. Singer
SF: Capgras syndrome: the delusion of substitution. J Clin Psychiatry 1987; 48:147-150 2. Cristodoulou GN: Syndrome of subjective doubles. Am J Psychiatry 1978; 135:249-251 3. Damas Mora JMR, Jenner FA, Eacott SE: On heautoscopy or the phenomenon of the double: case presentation and review of the literature. Br J Med Psychol 1980; 53:75-83 4. Benson Ri: Capgras’ syndrome. Am J Psychiatry 1983; 140: 969-978 D. VARTZOPOULOS, I. VARTZOPOULOS, Thessaloniki,
Dissociation
in Endogenous
M.D. M.D. Greece
Psychosis
SIR: Dissociation phenomena were major areas of clinical investigation during the time of Janet (1). Subsequently, there has been a decline of interest in these clinical syndromes, although there has been no evidence to suggest that the incidence of the phenomena has in any way diminished since that time (2). Conversion symptoms involving the sensonimotor system are frequently seen in patients with somatic diseases (3) and psychiatric disorders (4). Shalev and Munitz (5) reported a case in which conversion was associated with paranoid psychosis. The combination of dissociation phenomena and endogenous psychosis is not frequently reported in the literature. We report two cases from north India in which patients with endogenous psychosis also had dissociation symptoms. Ms. A, a 52-year-old married woman, had a diagnosis of bipolar affective disorder according to the DSM-III-R criteria. At the age of 45 years she had had her first attack of endogenous depression. This episode was characterized by sadness, weeping spells, suicidal ideas, insomnia, negative ideas, and psychomotor retardation. Since then she had been having one or two attacks of mania and depression every year. The manic attacks were characterized by increased psychomotor activity, inappropriate euphoria, and insomnia. She did not respond to lithium prophylaxis. She had been hospitalized three times, once for depressive illness and twice for manic excitement. After recovery from the third attack of depression, Ms. A began to have episodes of unconsciousness during which she would become unresponsive; these lasted for a few minutes to a few hours. Twice during these episodes, EEGs failed to show seizure activity. The episodes could be induced by suggestion, and she had partial amnesia for events during them. The episodes always occurred in periods of severe depression; she never experienced them during manic psychosis and symptom-free periods. Mr. B, a 23-year-old unmarried man, was an outpatient who had a diagnosis of schizophrenia according to the DSM-III-R criteria. His first attack of schizophrenia had occurred when he was 16 years old. His illness was charactenized by psychomotor excitement, violence, inappropriate affect, and suspiciousness. The symptoms did not remit after the first attack, and although he had been given regular maintenance injections of fluphenazine decanoate, he had been having one or two acute exacerbations every year. After improving from the second attack of the illness,
395
LETTERS
TO THE
EDITOR
he started to have episodes of unconsciousness lasting from 15 to 30 minutes, during which he would close his eyes and clench his teeth. He remained responsive to deep and painful stimuli but did not respond to verbal stimuli. He experienced three to five of these episodes a week, and they could be induced by suggestion. Twice during such episodes, EEGs did not show evidence of seizure activity. Both of these cases were characterized by concurrent endogenous psychosis and dissociation. The presence of dissociation in these patients could not be correlated with specific life events that were meaningful to them. Could the episodes of dissociation have been the result of release of psychotic anxiety? It is interesting to note that for each of these patients there was a time lag following the first episode of psychosis before the dissociation symptoms appeared. It is possible that in chronic patients, tolerance of stress becomes much less, and in these patients dissociation was precipitated by very minor stresses that could not be elicited by our repeated interrogation. This report clearly shows that neurotic phenomena are not only the domain of neurotic patients but that psychotic patients can also develop these symptoms.
REFERENCES 1. Janet P: The Major Symptoms of Hysteria. New York, Macmillan, 1987 2. Nemiah JC: Dissociative disorders (hysterical neurosis, dissociative type), in Comprehensive Textbook of Psychiatry, 4th ed, vol 1. Edited by Kaplan HI, Sadock BJ. Baltimore, Williams & Wilkins, 1985 3. Chaturvedi 5K, Upadhyaya MP, Rao P: Somatic complaints in a community clinic. Indian J Psychiatry 1968; 30:369-374 4. Gautam SK, Kapur RL: Psychiatric patients with somatic complaints. Indian J Psychiatry 1977; 19:75-80 S. Shalev A, Munitz H: Conversion without hysteria: a case report and review ofthe literature. BrJ Psychiatry 1986; 148:198-203 RAJEEV GUPTA, L.S. CHAWLA, Ludhiana,
Organic
Mental
Disorders
and
M.D. M.D. India
dens of delirium, dementia, and amnestic disorder within the overall rubric of cognitive impairment disorders. The second goal is to replace the term “organic” with a term that is more precise and less likely to perpetuate the false implication that the “nononganic” disorders lack a significant biological component in their etiology. We believe that the term “secondary,” as in “secondary mood disonden,” more cleanly conveys the DSM-III-R and lCD-i 0 constructs, namely, a disturbance of mood that is judged to be secondary to a nonpsychiatnic medical disorder. Dr. Lipowski believes that any confusion in the meaning of the term “organic” can be solved by the ICD-10 statement that the term merely means “that the syndrome so classified can be attributed to an independently diagnosable cerebral or systemic disease.” We doubt that this or any other attempt to redefine “organic” will succeed in overcoming the unfontunate historical baggage that the term has accrued. In fact, the wording of the lCD-i 0 statement is equivalent to the way in which we are proposing that the term “secondary” be used. The introduction of any change in psychiatric classification and terminology has the potential for creating shortterm confusion, since users have to learn new concepts. In this case, we feel that the long-term benefits in clarity and in improved differential diagnosis, on balance, justify what we regard as an important step forward in our nosology. With several of our colleagues on the Task Force on DSM-IV and the Work Group on Organic Mental Disorders, we are currently preparing a paper that makes a complete presentation of the proposal, including a historical review, as well as nesponses to critiques of the proposal.
REFERENCES 1. Lipowski ZJ: Organic mental disorders and DSM-IV (letter). Am J Psychiatry 1990; 147:947 2. Lipowsky ZJ: Is “organic” obsolete? (editorial). Psychosomatics 1990; 31:342-344 3. Spitzer RL, Williams JBW, First MB, et al: A proposal for DSMIV: solving the “organic/nonorganic problem” (editorial). J Neuropsychiatry Clin Neurosciences 1989; 1:126-127 4. Popkin MK, Tucker G, Caine E, et al: The fate of organic mental disorders in DSM-IV: a progress report. Psychosomatics 1989; 30:438-441 ROBERT L. SPITZER, MICHAEL FIRST, GARY TUCKER,
DSM-IV
New
SIR: In this journal (1) and elsewhere (2), Z.J. Lipowski, M.D., has characterized a proposal to eliminate the category of organic mental disorders in DSM-IV as “idiosyncratic” and likely to “create confusion” and “impede communication.” This proposal was originally formulated by Robert L. Spitzcr, Janet B.W. Williams, Michael B. First, and Kenneth S. Kendler (3) and arose in response to concerns among work group members and experts in the field that the onganic/ nonorganic distinction had become anachronistic. The final proposal, presented by the DSM-IV Work Group on Organic Mental Disorders (4), has two main goals. The first is to facilitate differential diagnosis by grouping phenomenologically similar syndromes on disorders in the same major diagnostic class. Thus, the clinician, in determining the differential diagnosis of depressed mood, would find within the class of mood disorders what in DSM-III and DSM-III-R were called organic mood disorder and drug-induced mood disorders. A natural consequence of this approach is to retain together the traditional (pre-DSM-III) organic mental disor-
396
Dr.
Lipowski
York,
M.D. M.D. M.D. N.Y.
Replies
SIR: Dr. Spitzen and associates object to my critique of the proposed abolition of the category of organic mental disonders in DSM-IV, yet they fail to provide any convincing rcasons in support of this proposal. A term means no more and no less than its definition specifies and this applies to the term “organic” in the present context. I have just received the 1990 draft of chapter 5 of ICD-10, which contains a separate section called “Organic, Including Symptomatic, Mental Disorders.” It is introduced by a statement that “this section comprises a range of mental disorders grouped together on the basis of their having in common a demonstrable actiology in cerebral disease, brain injury, or other insult leading to cerebral dysfunction” (p. 30). It is further stated that “the term ‘organic’ means no more and no less than that the syndrome so classified can be attributed to an independently
Am
J
Psychiatry
1 48:3,
March
1991
![[Suicide and endogenous psychosis].](/assets/img/hold.png)
