Journal of Affective Disorders 359 (2024) 86–91

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Review Article

Unitary psychosis (Einheitspsychose): A conceptual history

Massimiliano Aragona *
Roman Circle of Psychopathology and Italian National Institute for Health, Migration and Poverty (INMP), Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Aims: The objective of this paper is to explore the evolution of the forms of madness and the model that accounts
Psychopathology for it over time. The classical distinction between several categories of mental disorders is contrasted with the
History of psychiatry idea of unitary psychosis.
Mood disorders
Methods: Historical conceptual analysis. The concept of unitary psychosis is explored in its basic features. Its
Schizophrenia
Bipolar disorder
origins in the nineteenth century and developments during the twentieth century are considered.
Unique psychosis Results: Following the publication of Kraepelin’s fundamental handbook, the debate was shaped as pro or against
the Kraepelinian dichotomy between dementia praecox and manic-depressive illness. However, the origins of the
concept of unitary psychosis as well as some more recent developments are independent from it.
Conclusions: This article argues that, when viewed pragmatically, both positions (the pluralist and the unitary)
bring advantages that can be complementary rather than mutually exclusive. The pluralist position allows us to
recognize the qualitative differences between phenomena and structures of experience, while the unitary model
prevents us from reifying them. This is achieved by paying attention to the diachronic evolution and the path­
ogenetic dynamics.

1. Introduction (disordered) thinking and speaking”. Overall, the term ‘psychosis’ today
refers to a severe mental illness characterized by the patient’s experi­
According to Bürgy (2008), the term ‘psychosis’ was first used in ence of a profoundly altered world, usually without awareness (or only
1841. However, by the end of that century, its general meaning as a partial awareness) of this alteration and without insight into the path­
synonym for madness was replaced by a narrower concept, i.e. the ological nature of this transformation.
psychic manifestation of a somatically based neurosis. The term ‘psy­ Three main questions arise in this context: First, what are the di­
chosis’ was defined between the end of the 19th century and the agnoses and the symptoms that should be considered ‘psychotic’? Sec­
beginning of the 20th century, ending up referring to a serious mental ond, is there a continuum between ‘psychotic’ and ‘non-psychotic’
disorder for which an organic aetiology was postulated (Beer, 1996). phenomena? Third, is there one psychosis or many psychoses? This third
Over time, the focus has shifted from the aetiological reference to the question has been addressed in different ways in different countries, but
symptomatic presentation, especially since the atheoretical DSM has can be generally defined as “The question of the unitary psychosis or
taken an officially agnostic position on the causes. One of the most multiple psychoses”. The last nosographic question is of central impor­
enduring aspects of the concept of psychosis is its severity, which is tance to this debate, although the other two questions are related.
expressed in both symptomatic terms (for example, the presence of According to Berrios and Beer (1994), unitary psychosis is the term
delusion and hallucinations) and/or in terms of loss of awareness of the used to describe various views that assert there is only one psychosis.
illness. A search of the term “psychosis” on Google today retrieves a text The arguments put forth to support this statement vary depending on the
from the National Institute of Mental Health of the United States (2023) authors, their geographical context, and the historical ages. Some ar­
as the first result (National Institute of Mental Health, n.d.). The text guments are based on conceptual/ontological approach, while others on
begins with the following incipit: “Psychosis is when people lose some clinical differences, statistical distribution, or aetiology. Berrios and
contact with reality. This might involve seeing or hearing things that Marková (2021, p.16) further suggest that “the concept of ‘unitary
other people cannot see or hear (hallucinations) and believing things psychosis’ is multivocal. What determines which meaning is current or
that are not actually true (delusions). It may also involve confused fashionable within each historical period is unclear. It is likely, however,

* Corresponding author at: INMP, Via di San Gallicano 25a, 00163 Roma, Italy.
E-mail address: [email protected].

https://doi.org/10.1016/j.jad.2024.05.099
Received 26 March 2024; Received in revised form 6 May 2024; Accepted 19 May 2024
Available online 20 May 2024
0165-0327/© 2024 Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

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M. Aragona Journal of Affective Disorders 359 (2024) 86–91

that it will depend less on the advances of science than on their temporal (Einheitspsychose). Beyond their different explanatory theories, the au­
economic and social value”. thors of these works share the idea that the various symptoms they
As Berrios and Beer (1994) have already written an unsurpassed describe do not represent distinct diseases but rather indicate different
conceptual history on the topic, we are pleased to refer to their work for stages in the clinical evolution of a single pathology. As for Griesinger,
further information. Here, we will limit ourselves to some conceptual the disease progresses according to a characteristic sequence of phases
aspects that are of a certain importance for the contemporary psycho­ that begins with affective disturbances and, if the disease advances, the
pathological debate. patient experiences a progressive delusional derailment, ultimately
reaching a manic phase. This, in Griesinger’s time corresponded more
2. The debate on unitary psychosis in the 19th century closely to psychomotor agitation than to the contemporary under­
standing of mania. At this point, if the process persists and continues to
The initial views on unitary psychosis gradually emerged from a evolve, the person will manifest serious and irreversible cognitive dis­
metaphysical vision. Accordingly, Berrios and Beer (1994, p.21) point orders, which today would be diagnosed as dementia. As observed by
out that, prior to 1750, “insanity tended to be considered as an all-or- Vliegen (1980), symptoms are therefore organized along a continuum
none metaphysical state relating to the body in an abstract way. The characterized by progressive worsening. Gualtieri (2019, p.51) further
mind was alienated in its entirety and the concept of partial insanity adds that in Griesinger, the concept of unitary psychosis has no bearing
could not be really countenanced”. on diagnostic boundaries between disorders; rather, it is a “description
A first scientific view on this subject is that of William Cullen’s about the development and course of psychopathological sufferance,
(1710–1790), who observed many instances of transitory cases of with the description of subsequent syndromic stages. In modern terms,
madness (i.e., forms of insanity from which the persons have entirely we could say that it has to do more with the dimensional diagnosis than
recovered) that are probably not due to lesions of the brain, but to with a categorical debate about the separateness of mental disorders”.
changes in its state of excitement. He criticizes ‘the ingenious’ Dr. However, it is also noteworthy that Berrios and Beer (1994) point out
Arnold who “has been commendably employed in distinguishing the that in the final phase of his life Griesinger would have significantly
different species of insanity”, believing they were based on brain dif­ revised his conceptions, influenced by the reading of Kahlbaum’s dis­
ferences. Cullen believes that these are “mere varieties” which appear to tinctions. This type of categorical change is not unexpected, given that it
him “to be often combined together, and to be often changed into one is consistent with Griesinger’s empiricist approach to be open to re­
another, in the same person; in whom we must therefore suppose a visions of the system based on new observations. However, his objective
general cause of the disease” (Cullen, 1827 pp.76–77; quoted in Berrios of revising the classification system was not achieved, as he passed away
and Beer, 1994, p.17). shortly after.
Of all the unitary views, the exemplary contribution of Whilelm
Griesinger (1817–1868) is the best known to the subject. Historically, 3. The Kraepelinian dichotomy
his work originated in the Belgian Joseph Guislain (1797–1860), whose
contribution was translated into German by Ernest Albert von Zeller Although Griesinger appears to have been influenced by Kahlbaum’s
(1804–1877).Through Zeller it reached Griesinger. It is necessary to approach of multiple diagnostic categories, historical evidence demon­
consider these authors in order, since the underlying theories change in strates that Kraepelin was actually the author who most effectively
sequence, but the central point remains constant and becomes increas­ interpreted this perspective.
ingly clear. As seen, the concept of unitary psychosis emerged before Kraepelin’s
For Guislain (1852), the basis of mental illness is phrenalgia (mental treatise and independently from it. However, for those who came after
pain), which ranges from simple suffering to melancholy. This common Kraepelin, it is typical to debate about the unitary psychosis having in
basis allows for the manifestation of different ‘irritants’ (worry, pain, mind the Kraepelinian dichotomy between dementia praecox and
annoyance) to produce a reaction that leads to different phrénopathies manic-depressive psychosis. However, what did Kraepelin really wrote
through stages of progressive deterioration. These then pass from a stage about mental illnesses?
of exaltation of the brain’s activity to one of aberration of the brain’s Firstly, Kraepelin regarded psychiatric diagnoses as morbid units, i.e.
structures, followed by their suppression until the psychic energy is categories corresponding to real diseases. He believed that these di­
exhausted. As for the symptoms, the progression from melancholia to agnoses should be (ideally) characterized by a convergence of brain
mania can be observed, followed by the development of paraphrenia, lesion, aetiology, clinical symptoms, course, and outcome. He held this
hyperplexia (stupidity), hyperspasmia (epilepsy), ideosynchysis (hallu­ idea for a long time, and only in later scripts this approach was partially
cinations), analcouthia (confusion), and finally, noasthenia (dementia). revised.
Berrios and Beer (1994) cite Zeller’s assertion that mental illness Regarding dementia praecox and manic-depressive psychosis, sur­
may have a mixed aetiology, including both organic and “moral” causes. prisingly the famous seventh edition of Kraepelin’s handbook does not
Among the moral causes, psychological pain due to remorse, a guilty indicate any dichotomy. Instead, these two diagnoses are presented
conscience, poverty, and reverses of fortune were identified as promi­ alongside numerous others. In particular, dementia praecox is posi­
nent. Even in Zeller, the initial symptom that emerges is melancholy tioned between thyroid psychoses and paralytic dementia, while the
which, as it intensifies, progress to mania, then paranoia, and ultimately manic-depressive illness is located in another section, immediately
dementia. following the madness of the elderly. The organization of the books and
Finally we consider Griesinger, who published the Pathology and the way they are discussed suggest that there is any particular rela­
therapy of mental illnesses in 1845 (Griesinger, 1845, 2017), a text that tionship between the two diagnoses.
will remain a classic in the field of psychiatry. Of particular interest is As for the symptoms of these diagnostic categories, mood distur­
Griesinger’s statement that “mental illnesses are diseases of the brain”, bances are present in the section on dementia praecox. However, this
and his subsequent designation as organicist in psychiatry. However, as does not result into diagnostic overlap or comorbidity. In Kraepelin’s
Gualtieri (2019) effectively argues, Griesinger sought to remain equi­ view, mood alterations are normally part of the clinical picture of de­
distant in the controversy between ‘psychic’ and ‘somatic’ psychiatrists. mentia praecox, and their presence does not question the categorical
Instead, it advocates an empirical approach, emphasizing clinical data distinction at the diagnostic level.
and real experience, while maintaining a willingness to revise the model In terms of differential diagnosis, Kraepelin highlights the difficulties
in light of new observations that may conflict with it. As a student of in distinguishing dementia praecox from a number of other clinical
Zeller, also known to have been influenced by Guislain, Griesinger was presentations: neurasthenic states, progressive paralysis, epileptic twi­
instrumental in developing the idea of the unitary psychosis light states, malingering, hysteria, paranoia, and also the depressive or

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M. Aragona Journal of Affective Disorders 359 (2024) 86–91

manic episodes of a manic-depressive psychosis. Conversely, several 4. The unitary view in the post-Kraepelinian debate: general
diagnoses must be considered in the differential diagnosis with manic- remarks
depressive psychosis, among which is dementia praecox: “It is more
difficult to distinguish simple retardation from the initial period of In the post-Kraepelin period, Berrios and Beer (1994) count many
depression in dementia praecox. In the manic-depressive patients the psychiatrists among the twentieth-century ‘unitarians’: Bonhoeffer,
psychomotor retardation […] stands out in contrast to the absence of Hoche, Kretschmer, Conrad, Llopis, Ey, Menninger, Rennert, Janzarik,
retardation, freedom of movement and thought, and to the clearness of Kendell, and Crow. Today, we could certainly extend the list by adding
consciousness in dementia praecox. Rapid appearance of senseless de­ authors from the last thirty years. However, rather than going into detail
lusions and numerous hallucinations without clouding of consciousness about each author, it seems more useful to highlight the theoretical
speak for dementia praecox” (Kraepelin, 1912, pp.416–417). Accord­ positions around which a concept of unitary psychosis coalesces. An
ingly, in the sections dedicated to the differential diagnosis, Kraepelin’s exception will be made for two authors who are particularly important
objective is not to contrast the two diagnostic categories but to avoid for our analysis.
misdiagnosis. This entails differentiating between the symptoms of de­ In the writer’s estimation, the main debate following the work of
mentia praecox and those of other diagnoses, including those of manic- Kreapelin can be described as follows, centered on a series of interre­
depressive illness, and vice versa, differentiating between the symptoms lated yet distinct concerns, rather than being a standalone issue.
of manic-depressive illness and those of other diagnoses, including those
of dementia praecox. 1. In statistical studies, there is no clear distinction between the domain
The distinction between schizophrenia and manic-depressive psy­ of schizophrenia and related disorders (today’s “schizophrenic
chosis became established as the two columns of psychiatric nosography spectrum”) and that of bipolar disorder and related affective disor­
over time. This development may be related to the influence of Bleuler’s ders. This topic, which is known as “the argument of the statistical
concept of the schizoid and syntonic personalities, which inscribed the distribution”, finds Kendell among its pioneering figures. Initially,
two diagnoses within a broader anthropological framework of two the studies observed that there was no area of rarity between the two
fundamental human kinds. diagnostic groups, indicating that the phenomena were not divided
In any case, by the end of his life, Kraepelin himself had begun to into two distinct areas according to a bimodal distribution. Later,
consider schizophrenia and manic-depressive psychosis in opposition to factor analysis has been employed to identify a general psychotic
each other, as if the idea of a dichotomy had finally been taken for factor underlying various psychoses, both acute and chronic (e.g.,
granted. Reininghaus et al., 2013).
Interestingly, in 1920 Kraepelin (1974) published a paper which is 2. Other research has found that Schneiderian first-rank symptoms are
frequently cited by proponents of the dimensional diagnosis in opposi­ not exclusive to schizophrenia but are also observed in bipolar pa­
tion to the categorical model. This paper is often presented as evidence tients (e.g., Carpenter Jr. et al., 1973), although more frequent and
that Kraepelin had abandoned his original idea of a categorical severe in schizophrenics (Rosen et al., 2011). It was deduced that
distinction between the two psychoses. In reality, Kraepelin’s self- there is no specific symptomatology of schizophrenia, whose symp­
criticism should not be interpreted as a transition to the dimensional toms are not clearly distinguishable from those of mood disorders.
diagnosis or a revision of his classification. Rather, it should be regarded 3. Another approach is that of aetiology studies, which aim to identify
as a critique of the fundamental concept of morbid units. Indeed, he the common causes of psychosis, regardless of superficial phenom­
acknowledges that the clinical symptoms are insufficient to clearly enal differences. In this context, we may distinguish between classic
distinguish between manic-depressive psychosis and schizophrenia. He and more recent versions. Among the former is Rennert
also raises doubts about the likelihood of discovering a somatic aeti­ (1920–1994), whose ideas were controversial with Leonhard, and
ology for these syndromes, although he still believes it is possible with who proposed the concepts of “universal genesis” and “basic psy­
the advancement of knowledge. In an intriguing passage of the book, chopathological complex” (psychopathologischen Basiskomplex).
Kraepelin (1974, p. 28) writes that “however, we must at all costs adhere Among the latter, an example is the work of Kikuyama et al. (2017),
to the basic difference between the disease processes concerned”. This who argues that the idea of separate mental disorders should be
critique of the diagnostic distinction between schizophrenia and manic- rejected in favour of a spectrum model of mental illnesses, united by
depressive psychosis is not merely revision of his model of the morbid the same genes are related to different disorders (intellectual disor­
units; it opens up to a more dynamic interplay between the biological ders, autism, ADHD, schizophrenia, bipolar disorder and
basic disturbances and the personality. According to this revised view, depression).
the same biological disturbance can lead to different final clinical pic­
tures depending on the kind of personality involved. For example, he These approaches share a similar argument: 1. A dichotomy is
writes that “the affective and schizophrenic forms of mental disorder do assumed to exist between schizophrenia and manic-depressive psycho­
not represent the expression of particular pathological processes, but sis. 2. Studies have shown that the aforementioned entities are not truly
rather indicate the areas of our personality in which these processes separate in terms of their statistical distribution, distribution of symp­
unfold” (Kraepelin, 1974, p.28). toms, or commonality of genes. 3. Therefore, the dichotomy is rejected
In Kraepelin’s conceptual development, we find firstly a nosographic in favour of a model of unitary psychosis.
distinction. This distinction allows for the differentiation between A further point of convergence among these studies is that they all
different morbid units despite the presence of some affective symptoms focus on criticizing the Kraepelinian dichotomy but do not propose a
in dementia praecox and of some symptoms of dementia praecox in well-articulated alternative psychopathological model. Instead, they
manic-depressive psychosis. Secondly, we find a nosological critique, suggest the need to think in terms of a continuum or spectrum. In
with a decline in the trust placed in severed morbid units due to the contrast, in the following two sections present two distinct psycho­
overlapping and unclear aetiology of symptoms. However, the cate­ pathological proposals. The former proposes the categorization of many
gorical distinction is not abandoned. Finally a dynamic proposal psychoses, while the latter supports a unitary model.
emerges, suggesting that a common noxa may result in different symp­
toms based on the structure impacted. 5. The post-Kraepelinian splitting in several psychoses

Probably the most illustrative example of this position is exemplified

by Karl Leonhard (1904–1988).
As outlined by Lanczik and Fritze (1992), Karl Leonhard’s

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M. Aragona Journal of Affective Disorders 359 (2024) 86–91

classification of endogenous psychoses is part of a tradition that builds Dynamische Grundkonstellationen in endogenen Psychosen (Janzarik,
upon the work of Carl Wernicke and Karl Kleist, emphasizing the 1959), begins with a criticism of Kraepelin and then proposes a rather
interface between biology and psychopathology. Leonhard’s criticism of different system whose key concepts are ‘dynamics’ and ‘structure’.
Kraepelin’s dichotomy does not lead to questioning the categorical The dynamics refers to the endogenous, biologically anchored
diagnosis, in contrast to the authors previously cited. Instead, Leonhard ground, and is the sphere of emotions, impulses and intentions. The
proposes an even sharper differentiation of several forms of endogenous structure refers to the psychic contents that remain stable throughout
psychoses, all considered as distinct disease entities. This position is life. Janzarik emphasizes the role of values in maintaining the stability
evident from the outset of his fundamental book (Leonhard, 1966), of the structure.
where the author claims that although Krapelin had made valuable As outlined by Dalle Luche et al. (2023), Janzarik’s main thesis is
observations about psychoses, his fundamental distinction based on that endogenous psychoses are primarily caused by alterations of the
prognosis (incurable schizophrenia, favourable prognosis for the manic- dynamics, while organic diseases are attributed to a primary failure of
depressive psychosis) was overlooked, and psychiatrists had lost interest the cognitive system. In a unitary view of endogenous psychoses, the
in the differentiation of the psychoses. In order to provide a compre­ dynamic movements of reduction, expansion, instability and exhaustion
hensive description, the aim is to describe “specific diseases” where a impact the structure, giving rise to the different symptomatic expres­
specific clinical picture (described in all details and nuances), a common sions of psychosis over time. The core chapters of the Grundkon­
familiarity (genetic diathesis), and a specific course converge. Accord­ stellationen are dedicated to an analysis of the various “dynamic basic
ingly, Leonhard distinguishes the following forms of endogenous psy­ constellations” that characterize the endogenous psychoses. In partic­
choses: those with a favourable prognosis include the phasic psychoses ular, during depressive phases there is a dynamic reduction, which may
(manic-depressive psychosis, pure melancholy and pure mania, pure be defined as a generalized drop in energy and activity, while at the
depressions and pure euphoria) and the cycloid psychoses (anxious- cognitive level the values of the structure are maintained. In contrast,
ecstatic psychosis, excited-inhibited confusional psychosis, and manic states are distinguished by dynamic expansion, characterized by
hyperkinetic-akinetic motor psychosis). Those with a negative prognosis an excess of dynamic movement, with the maintenance of structure. The
include the non-systematic schizophrenias (affective paraphrenia, dynamic constellations of schizophrenia differ in acute and chronic
schizophasia/cataphasia, and periodic catatonia) and the systematic schizophrenia. At the onset of the illness, when the patient experiences
schizophrenias (catatonic, hebephrenic, and paranoid forms). an increase in their intuitive abilities with a preponderance of external
For the purpose of this discussion, it is relevant to note that: impressions, there is a dynamic expansion. The difference between this
and mania is that in schizophrenia the dynamics is not just expanded,
a) This represents a further strengthening of the idea that every syn­ but also unstable. This instability is made possible by the simultaneous
drome corresponds to an illness, years after Kraepelin’s partial collapse of the structure, which is no longer able to contain the emer­
retraction of the morbid units. gence of unstable ideas. Finally, in long-standing schizophrenia the
b) The affective disorders are subdivided into different diseases, which exhaustion of the dynamics leads to a dynamic insufficiency with a
are supposed to have not only different symptoms but also different reduction in emotional impetus and planning. The structural objects are
aetiologies. subjected to atrophy and disintegration, resulting in a complete chaotic
c) The clinical distinction between manic-depressive psychosis and state of the remaining structure.
pure affective disorders is based on the presence of mixed symptoms As can be discerned from the text, Janzarik maintains a general
in the former (polymorphous picture), while in the latter forms, the reference to the traditional nosography and also exhibits a tendency to
clinical picture recurs consistently in different episodes, without distinguish different forms of psychoses. However, these distinctions do
changes or a counterpolar switch. not refer to categorical morbid units but to different phenomenal forms
d) The clinical distinction between pure melancholy and mania on the along a continuum. Indeed, there is one basic dynamic change which,
one hand, and pure depression and euphoria on the other, is based on depending on the impact on the structure, can progress from mood
the involvement of affectivity, ideation and will in the former group, disturbances to acute forms of schizophrenia and finally to chronic
and only affectivity in the latter. disarticulation and chaos.
e) The cycloid psychoses (anxious-ecstatic psychosis, excited-inhibited The model of another prominent psychopathologist, the French
confusional psychosis, and hyperkinetic-akinetic motor psychosis) Henri Ey (1900–1977), refers to John Hughlings Jackson’s (1884)
present a clinical challenge in differentiating them from the non- Croonian lectures as the first theoretical reference in his organodynamism,
systematic schizophrenias (affective paraphrenia, schizophasia/cat­ thus predating Kraepelin. Jackson’s ideas had already played an
aphasia, and periodic catatonia). However, their prognosis differs important role in the theoretical development of great French psychia­
(favourable in the first group, negative in the second), thereby sug­ trists, such as Pierre Janet and Gaëtan Gatian de Clérambault. This
gesting a distinction between these two categories despite the sim­ cultural context, largely independent of Kraepelin, is the one to which
ilarieties between symptoms. Ey refers. In the Croonian lectures, Jackson argued that many symptoms
f) The presence of symptoms typically associated with schizophrenia in should not be seen as the output of brain lesions, but rather as liberation
some affective disorders, and of affective symptoms in the schizo­ phenomena linked to the failure of superordinate inhibitory systems.
phrenias, does not invalidate the distinction between the two cate­ Azima (1953) suggests that in Ey’s organodynamism the organism is
gories, which continue to remain different natural kinds. viewed as a being in progress, which could potentially lead to dynamic
consequences in the case of organic problems. In particular, since the
6. Two post-Kraepelinian dynamic unitary views functions are organized hierarchically, in psychiatric pathologies, a
reduction in global psychic tension leads to a dissolution of the higher
In our previous discussion of criticisms of the Kraepelinian di­ psychic functions, with the subsequent liberation of the lower ones.
chotomy, we explored the notion of continuity at various levels between Neurotic, higher-level phenomena would initially appear, followed by
the two major psychoses. We remarked that these theories propose psychotic lower-level phenomena when the dissolution of consciousness
forms of dimensional continuity between the diagnoses, but do not progresses. Noteworthy, Ey’s theory is not limited to the description of a
propose complex alternative psychopathological models. The following sort of mental automatism. It has been argued (Aragona, 2020) that Ey’s
two authors provide illustrative examples of unitary views that are most relevant contribution is his law of the organo-clinical gap, which he
radically divergent from the idea of a sharp dichotomy and suggest a defines as follows: “between the symptom and its organic aetiology
complex dynamic model. there is a gap [écart] that constitutes the overall complexity of mental
The German Werner Janzarik (1920–2019), author of the book pathology. Between the knock that the brain receives and the clinical

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M. Aragona Journal of Affective Disorders 359 (2024) 86–91

picture, there is the personality of the ill person” (Ey, 1934, p.22). In of mental automatism. Ey addresses these themes by discussing the
other words, in many psychiatric conditions the alteration of con­ destructuring of consciousness, presenting a unitary model that appears
sciousness does not directly provoke emergence of automatic, low-level to come directly from the 19th century, projecting itself into the future
outputs. The final symptoms are a dynamic product, i.e., the result of an regardless of Krapelin’s assertion.
implicit elaborative process carried out by the subject based on their In a detailed critical work, Del Pistoia and Dalle Luche (1993) assert
unique personality. This is the core of Ey’s unitary model, as it suggest that nearly two centuries after Griesinger, psychiatry has yet to over­
that in the same person, at different times and depending on fluctuation come the impasse that had led the great Swiss-German psychiatrist to
in the levels of lowering of psychic tension, different syndromic mani­ conceive the Einheitpsychose. They suggest that the two models − the
festations may appear, which may also progress or regress over time. unitary one and the categorical pluralist one − should continue to
diverge in a perpetual Heraclitean conflict. However, it is likely that the
7. Discussion optimal approach is to integrate both perspectives, avoiding radicali­
zations that, in the case of psychiatry and in history alike, tend to impede
This brief overview of the debate on unitary psychosis over the past rather than facilitate progress. It can be argued that, from the perspec­
two centuries may be useful in orienting current debates. tive of the present day, both of these positions are invalid if generalized,
First, the idea that the dispute on the existence of unitary psychosis is but may be useful if considered pragmatically.
a discussion for or against Kraepelinis is questionable. It is true that The radical Kraepelinian or neoKraepelinian views aim to establish a
several studies in the second half of the twentieth century explicitly took categorical classification of mental illnesses as if they were medical
a position against the Kraepelinian dichotomy, and also that the out­ diseases. Nevertheless, the history of medicine shows that by the 18th
comes of many studies have supported the idea of a continuum or of a century, numerous diseases had already been distinguished based on
possible unitary psychosis, against Kreapelinian categorizations. How­ subtle symptomatic distinctions. However, only a small number of these
ever, it is essential to acknowledge that: survived in the new classification of diseases based on the discovery of
aetiopathogenesis. In psychiatry, the vast majority of diagnoses continue
a) Initially, Kraepelin did not conceive a clear dichotomy, and when the to be based exclusively on phenomenological observations. As with
idea finally took hold, he himself began to criticize his first positions eighteenth-century medicine, it is inevitable that even with respect to
by proposing a more dynamic model, though he never entirely the current psychiatric classification, some distinctions will remain
rejected his original approach. while others will be abandoned.
b) There are examples of authors (e.g. Leonhard) who criticize the On the other hand, the unitary psychosis model rightly acknowledges
Kraepelinian dichotomy but do not suggest to replace it with unitary that psychopathological phenomena evolve over time, with the course
psychosis. Rather, Leonhard proposes an even more subtle categor­ often diverging from its initial trajectory. In the most radical version,
ical model, in which the two main psychoses are replaced by a however, there is the questionable idea that this course is structured
greater number of specific psychoses. according to a predictable sequence (which is plausible in some cases,
c) In any case, the debate on unitary psychosis originated well before but not in all). Additionally, there is the idea, also questionable, that
Kraepelin and his dichotomy, with the Einheitpsychose being essen­ there is only a single form of madness (while it is likely that there may be
tially a nineteenth-century idea. structurally different ways of presenting mental suffering).
However, if we reject totalizing visions and open ourselves to the
Secondly, in the nineteenth-century, the debate was not primarily potentials of the two models, we can say that on the one hand (the
focused on nosography. Rather, the main need was to account for the pluralist part), it is reasonable to think that there may be different
clinical evolution of the symptoms and to seek an explanation for them. syndromes that can have the following characteristics:
Thus, Griesinger emphasized the importance of clinical observation and a) Different causes and/or motivations (to put it in Jaspers’ terms);
suggested that symptoms evolve over time, and that cases initially pre­ b) Personality structures that take a different position in the face of
senting with affective symptoms can progress towards dementia. As the uncanny and the shapeless that emerges in their experience (on this,
there was not yet a clear distinction between neurological and psychi­ see Aragona et al., 2024);
atric pathologies, it is challenging to determine whether his observations c) Different ways of being in the world, which open up in different
pertained to patients who, in the current diagnostic framework, would ways to the possibility of different disturbing experiences and which
be diagnosed with a neurological disease accompanied by psycho- construct their situations of vulnerability in different ways (as shown by
organic symptoms, or to patients who would be classified as psy­ many authors in the phenomenological tradition);
chotic. In any case, it can be summarized by stating that in Griesinger the d) Symptoms that appear similar but, in fact, instead show a different
issue of unitary psychosis is not nosographic but mainly nosodromic. As structure depending on their classification within a specific syndrome
previously mentioned, shortly before his death Griesinger also addressed (see for example Jaspers’ classical distinction between primary and
the issue of categorical nosographic distinctions. However, he did not secondary delusions).These differences support the pluralist view sug­
have the opportunity to further develop this topic. gesting that it is not necessary to view everything through single lens.
Thirdly, it should be noted that the twentieth-century debate is not Again, these observations do not indicate that morbid units, understood
entirely centred on the Kraepelinian dichotomy. Indeed, there are ex­ as distinct natural entities, always exist in reality, nor do they suggest
amples of authors who propose a model of unitary psychosis indepen­ that the current categorical distinctions are the right ones. In light of
dent of Kraepelin (e.g. Ey) or that begin with a criticism of Kraepelin and this, there is space for a rearrangement of current nosological categories,
then develop an independent dynamic model (e.g. Janzarik). In partic­ which in certain cases could result in the unification into larger cate­
ular, Ey’s organodynamism builds upon a Jaksonian theme that had gories, spectra or dimensions.
emerged in French psychopathology between the 19th and 20th cen­ Alternatively, the unitary view proposes that:
turies. This theme shifted from an original neurological focus to a more a) In some cases, the study of the course indicates an evolutionary
general mental context. This shift involved moving from the model of continuity between symptoms of different diagnostic categories;
the epileptic discharge as a phenomenon of liberation due to the b) This facilitates a more comprehensive understanding of the lon­
disappearance of the inhibitory function of the hierarchically superior gitudinal psychopathological dynamics, rather than limiting ourselves
neurons, to the model based on a lowering of psychic tension. Examples to the transversal description of merely superficial symptoms;
of this latter phenomenon include Janet’s psychasthenia, responsible for c) This enables the identification of underlying connections that are
the emergence of obsessive and other psychasthenic phenomena that are obscured by diagnostic fragmentation.
no longer controlled and modulated, and de Clerambault’s description These observations support the unitary view suggesting ways to

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M. Aragona Journal of Affective Disorders 359 (2024) 86–91

avoid the risk of becoming lost in a kaleidoscope of appearances References

generated by the current diagnostic fragmentation. However, they do
not indicate neither that there can only be one psychosis, nor that there Aragona, M., 2020. Phenomenology of hallucinations: the contribution of Henri Ey’s
organodynamism to the appraisal of qualitative differences. Dial. Phil. Ment. Neuro.
is only one possible dynamic model that explains all mental pathology. Sci. 13, 8–12.
Indeed, it seems that both Janzarik’s model (oscillation of the endoge­ Aragona, M., Mancini, M., Scudiero, M., Stanghellini, G., 2024. Position-taking: an
nous ground of the “dynamics” which affects the structure) and Ey’s example of philosophical contribution in refining clinical practice in mental health.
In: Fiorillo, A., Falkai, P., Gorwood, P. (Eds.), Mental Health Research and Practice:
model (progressive destructuring of consciousness) have not only un­ From Evidence to Experience. Cambridge University Press, Cambridge, pp. 197–209.
doubted merits, but also the limitation of wanting to reduce all symp­ Azima, H., 1953. Fundamentals of a neo-Jacksonian conception of psychiatry and
tomatology back to a single explanatory unit, from where to derive the neurology. Henri Ey’s “organodynamism”. Arq. Neuropsiquiatr. 11, 360–370.
Beer, M.D., 1996. Psychosis: a history of the concept. Compr. Psychiatry 37, 273–291.
protean symptomatology. https://doi.org/10.1016/s0010-440x(96)90007-3.
It appear that the two models (the unitary and the pluralist) should Berrios, G.E., Beer, D., 1994. The notion of a unitary psychosis: a conceptual history.
not be considered as absolute alternatives; it is not necessary to choose Hist. Psychiatry 5, 13–36. https://doi.org/10.1177/0957154X9400501702.
Berrios, G.E., Marková, I., 2021. Historical epistemology of the “unitary psychosis”. In:
between them. On a psychopathological level, the two perspectives can
Tamminga, C.A., Ivleva, E.I., Reininghaus, U., van Os, J. (Eds.), Psychotic Disorders:
be complementary. On the one hand, differentiating the syndromes al­ Comprehensive Conceptualization and Treatments. Oxford University Press, New
lows us to highlight their qualitative specificities, which in turn allows York, pp. 12–20.
for the development of different therapeutic approaches and projects. Bürgy, M., 2008. The concept of psychosis: historical and phenomenological aspects.
Schizophr. Bull. 34, 1200–1210. https://doi.org/10.1093/schbul/sbm136.
For instance, hallucinations are structurally different in schizophrenia Carpenter Jr., W.T., Strauss, J.S., Muleh, S., 1973. Are there pathognomonic symptoms in
and in post-traumatic reactions. Attempting to explain them as a unitary schizophrenia? An empiric investigation of Schneider’s first-rank symptoms. Arch.
phenomenon that must be understood as either traumatic or psychotic is Gen. Psychiatry 28, 847–852. https://doi.org/10.1001/
archpsyc.1973.01750360069010.
misleading (Maggiora et al., 2021). On the other hand, by recognizing Cullen, W., 1827. The Works of William Cullen. Blackwood, London.
the evolutionary continuity of certain pathways and focusing on the Dalle Luche, R., Giovannini, S., Maggini, C., 2023. An updated review of Werner
dynamics that give rise to superficial symptoms, it is possible to avoid Janzarik’s psychopathological model of endogenous (idiopathic) psychoses.
American Journal of Psychiatry and Neuroscience. 11, 55–63. https://doi.org/
reifying meaningless elements. For example, diffuse and unstable 10.11648/j.ajpn.20231103.11.
anxious and depressive experiences are common in the early stages of Del Pistoia, L., Dalle Luche, R., 1993. La “psicosi unica” tra paradigmi nosografici non
future psychosis, with pathways that are not predetermined, and occa­ categoriali e strutture di senso in psicopatologia [The “unitary psychosis” between
non-categorical paradigms and structures of sense in psychopathology]. In: Asioli, F.,
sionally exhibit pluripotent, transdiagnostic trajectories (McGorry et al., Ballerini, A., Berti Ceroni, G. (Eds.), Psichiatria nella comunità. Cultura e pratica
2018). [Psychiatry in the community. Culture and practice]. Bollati Boringhieri, Torino,
In conclusion, the clinicians may benefit from qualitative phenom­ pp. 13–35.
Ey, H., 1934. Hallucinations et délire [Hallucinations and delusion]. Librairie Felix
enological distinctions between seemingly similar symptoms in order to
Alcan, Paris.
highlight different basic structures and facilitate the selection of more Griesinger, W., 1845. Die Pathologie und Therapie der psychischen Krankheiten
specific treatments. This should also help researchers in avoiding the [Pathology and Therapy of Psychic Diseases]. Verlag von Adolf Krabbe, Stuttgart.
inclusion of heterogeneous conditions in their samples. On the other Griesinger, W., 2017. On psychic diseases. Dial. Phil. Ment. Neuro. Sci. 10, 66–72.
Gualtieri, I., 2019. W. Griesinger: an approach towards the “body-mind problem” and the
side, mental illness is rarely the result of an objective noxious entity unitary psychosis. Dial. Phil. Ment. Neuro. Sci. 12, 48–52.
impacting an otherwise healthy organism. Rather, in many cases, it can Guislain, J., 1852. Leçons orales sur les phrénopathies, 1. Hebbellynk, Gand.
be the dynamic response of intrinsically vulnerable beings to basic un­ Jackson, J.H., 1884. The Croonian lectures on evolution and dissolution of the nervous
system. Br. Med. J. 1, 660–663. https://doi.org/10.1136/bmj.1.1215.703.
canny experiences subjectively perceived as a threat to their unstable Janzarik, W., 1959. Dynamische Grundkonstellationen in endogenen Psychosen
equilibrium (Stanghellini, 2024). The consideration of both options can [Dynamic Basic Constellations in Endogenous Psychoses]. Springer, Berlin.
enrich clinical and research procedures, thereby increasing the psychi­ Kikuyama, H., Kanazawa, T., Tarutani, S., Okayama, T., Yoneda, H., 2017. The unitary
psychosis theory. Brain Nerve 69, 657–664. https://doi.org/10.11477/
atrist’s freedom to choose the most relevant perspective, enhancing the mf.1416200797.
patient’s possibility to make sense of his/her experience, and high­ Kraepelin, E., 1912. Clinical Psychiatry. For Students and Physicians. Forgotten Books,
lighting the possibility of change over time. London.
Kraepelin, E., 1974. Patterns of mental disorders. In: Hirsch, S.R., Shepherd, M. (Eds.),
Themes and Variations in European Psychiatry. Wright & Sons, Bristol, pp. 7–30.
Funding source Lanczik, M., Fritze, J., 1992. Leonhard-Klassifikation endogener Psychosen—erste
biologische Befunde und differentialtherapeutische Erwägungen [The Leonhard
classification of endogenous psychoses—initial biological findings and differential
None.
therapeutic considerations]. Fortschr. Neurol. Psychiatr. 60, 296–304. https://doi.
org/10.1055/s-2007-999149.
CRediT authorship contribution statement Leonhard, K., 1966. Aufteilung der endogenen Psychosen [Distinction of endogenous
psychoses]. Akademie Verlag, Berlin.
Maggiora, M., Naim, S., Aragona, M., 2021. Hallucinations in schizophrenia and PTSD.
Massimiliano Aragona: Writing – original draft, Conceptualization. Idealtypical psychopathological differences. Dial. Phil. Ment. Neuro Sci. 14, 46–59.
McGorry, P.D., Hartmann, J.A., Spooner, R., Nelson, B., 2018. Beyond the “at risk mental
Declaration of competing interest state” concept: transitioning to transdiagnostic psychiatry. World Psychiatry 17,
133–142. https://doi.org/10.1002/wps.20514.
National Institute of Mental Health. Overview – Psychosis. https://www.nhs.
None. uk/mental-health/conditions/psychosis/overview/#:~:text=Psychosis%20is%
20when%20people%20lose,not%20actually%20true%20(delusions) (accessed 17
November 2023).
Acknowledgments Reininghaus, U., Priebe, S., Bentall, R.P., 2013. Testing the psychopathology of
psychosis: evidence for a general psychosis dimension. Schizophr. Bull. 39, 884–895.
The author thanks Angela Forese for her help in revising the English https://doi.org/10.1093/schbul/sbr182.
Rosen, C., Grossman, L.S., Harrow, M., Bonner-Jackson, A., Faull, R., 2011. Diagnostic
language. and prognostic significance of Schneiderian first-rank symptoms: a 20-year
longitudinal study of schizophrenia and bipolar disorder. Compr. Psychiatry 52,
126–131. https://doi.org/10.1016/j.comppsych.2010.06.005.
Stanghellini, G., 2024. The dynamic paradigm of illness in psychopathology. World
Psychiatry 23, 163–164. https://doi.org/10.1002/wps.21175.

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