Chakalova, V.

Damyanova, E.

Dimitrova, A.

Todorov, S.

English

Varna Medical University Press: Journals

CONCERNING THE CLINICAL SIGNIFICANCE OF THE SYNDROME OF PSYCHIC AUTOMATISM S. Todorov, A. Dimitrova, E . Damyanova, V . Chakalova Key-words: psychic automatism - clinics - depersonalization - alienation - schizophrenia Syndrome of psychic automatism (syndrome of Kandinskiy-Clerambault) as one of usual syndromes in psychopathology was an object of numerous investigations, especially in French and Soviet psychiatry. Different problems were discussed, e.g. of its etiology and pathogenesis, of its role in psychosis formation, of interrelations of its components, of peculiarities and speci-ficity of this syndrome in nosologically different psychotic states. Notwithstanding these in-vestigations, it can be definitely said that both limits and clinical significance of the syndrome in the general and also in the special psychopathology are not exactly and clearly outlined. Re-cently, it becomes evident that phenomena of psychic automatism are very difficult to fit in within the term "syndrome" because they represent by themselbes such a "dynamic series of derangements of the self-developing pathological process that can be rightfully divided into nu-merous syndromes passing one into another" (1). All that can be explained in an extent by the phenomenological complexity of psychic automatism and by the existing tendency of broaden-ing the psychopathological events incorporated in it. Historically. J. Baillarger (1846) when introducing this syndrome relates the term "psychic automatism" with definite psychic disorders, mainly with psychic hallucinations described by hiniself. J. Seglas (1888), P. Janet (1889), and A. Ceillier (1927) enlarge this concept accepting that psychic automatism means any event which originates ungratuitously. G. de Clerambault (1925) indicates that "psychic automatism is susceptible to a broader or narrower perception". He uses it in an "extraordinary narrow sense" in order to describe "a certain clinical syndrome comprising of three kinds of phenomena: motor, senesthopatic, and ideoverbal". Accoridng to him, this syndrome is a core one concerning chronic hallucinatory psychoses and delusions for persecution, influence, overcoming as well as hypochondric ones originate secondarily concern-ing this syndrome. However, this assumption has inimediaiely caused objections. G. de Cleram-bault's concepi about psychic automatism wins recognition in French psychiatry to desginate, on the one hand, a group of psychopathological disorders, and, on the other one, a definite me-chanism of psychopathological disorder formation. Syndrome of psychic automatism is not accepted, or more exactly, does not enter the Ger-man literature although psychopathological phenomena included (thoughts' deprivation, thoughts' transfer, "performed" phenomena, perception of influence, etc.) are studied in detail and considered more or less important as specific disturbances occurring in schizophrenia (14). This is probably due to the historically appeared concurrence between French and German psy-chiatry. Undoubtedly, the groundworks on the theory of psychic automamtism in Russian and Sov-iet psychiatry are laid by V. Kh. Kandinskiy. He gives a full description not only of pseudo-hallucinations but also of a series of otheir symptoms included along with them in !h?, syndrome of psychic automatism (phenomena of forcible thinking, feelmg of intrinsic revealedness, £tc). That is why the denomination of this syndrome, accepted in Soviet psychiatry as "syndrome of Kandinskiy-Clerambault" is perfectly fair in eponymous respect. According to A. V. Snezhnevs-Concerning the clinical. 77 kiy (1983), typical and characteristic in nowadays conception of this syndrome are "alienation, loss of belonging of one's own psychic actions, ffeling of constant influence of external pow-ers". This definition comprises most-essential criteria for differentiation between the syndrome of psychic automatism and the rest psychopathological syndromes. In order to create a more adequate evaluation of the clinical significance of the syndrome of psychic automatism one has to analyze some phenomenological questions in general psychopa-thological and clinico-nosological aspect. Development of psychic automatism as a whole in quite concise form looks like follows: in the very beginning of the disease subjective psycho-physical events are perceived by the patient as events belonging to himself but together with a certain feeling for liniitation, loss of freedom and spontaneousness. Then feeling for ungrati-tuitousness occurs and gradually, that one for personality alienation increases. Later on the idea for external interference appears together with conviction of foreign influence. All the pheno-mena mentioned together with pseudohallucinations lorm the entire picture of the syndrome of psychic automatism. However, the pathological process does not always stop its development at this stage but it progresses and results in an appearance of paraphreniae or in acute cases - of oneiroid syndromes. This dynamics described presents the most frequent variant. At the same time, a series of other variants are known which v iU not be discussed in this paper. From general-psychopath ological point of view the problem of correlation between psychic automatism and depersonalization in the concept of psychic automatism is the most difficult and uncleared one. G. de Clerambault has been convinced of the idea that primary personality disorders preceed even the appearance of elementar automatism changes, i.e. they preceed "small" automatism (petit automatisme). They are manifested in obsession of oppressive spirits, of somatopsychic unsteadiness accompanied by a rather vague feeling for ungratuitousness and the idea of certain external influence. It seems that psychic automatism and depersonalization both are product of one and the same pathological process without being identical, however, in constrast to A. A. Perelman's (1931) view, even because of that fact that depersonalization exists without psychic automatism, too, but the latter does never occur without depersonaliza-tion, indeed. Our investigations covering a total of 140 patients with schizophrenia with the syndrome of psychic automatism also show that depersonalization reflecting the negative side of mental disease appears primarily or at least together with psychic automatism (its most ini-tial forms) and progresses in the course of psychic automatism reaching at last to a total change of personality core (an automatism in the hands of external forces). "Alienation" occupies a special place in the structure of psychic automatism. In this respect, as far as processual depersonalization reflects the contiguous lowering of personality level it can be supposed that automated psychic formations existing in the norm would also undergo des-truction. Proceeding from this statement, A. A. Megrabyan (1962, 1972) launches the opinion expressed long ago that phenomena described in a finished state by G. de Clerambault are not psychic automatism at all but, on the contrary, they are disautomatization of psychic proces-ses. It is evident that problems are rather disputable and at this stage contemporary knowledge can hardly enable the acceptance of unidirectional solutions. However, we would like to men-tion in a critical aspect that consciousness and its highest degree - self-consciousness are pa-thologically changed at the very beginning of the disease which is manifested in initial deperso-nalization signs actually prior to symptoms of psychic automatism. In nosological aspect, the syndrome of psychic automatism is related first of all with schizo-phrenic psychosis. It originates in the course ot acute and chronic paranoid-hallucinatory states. In the first case the hallucinatory variant of syndrome is detected predominantly and in the se-cond - the delusional one (in dependence of that whether pseudohallucinations or delusions of influence prevail). Clinical peculiarities of the syndrome are determined to a certain extent by the type of schizophrenia course. Our investigations show that, according to the classification scheme of A. V. Snezhnevskiy et al. (1969), there are three typological variants of formation and manifestation of the syndrome of psychic automatism corresponding to three cardinal types 78 S. Tod rov, A. Dimitrova, E . Damyanova. of schizophrenia course. In cases of continuous course appearance and development of the syn­drome is gradually, enriching itself uninterruptedly by new and new symptoms in order to get at last with some patients to suffering of total automated subordination to delusions of influen­ce. Usually, a definite continuity of development can be seen, from symptoms 6f association automatism towards symptoms of senesthopatic and motor one. However, in cases of paro-xysmal-progredient course no definite continuity of appearance of symptoms can be observed. They originate almost simultaneously and become manifested to a certain extent still in the first days of psychosis without any further development. When they, however, develop there is a transition from paroxysmal-progredient towards continuous psychosis course. In cases of paroxysmal schizophrenia course the syndrome of psychic automatism develops rapidly in clos­est relation to acute paraphrenic syndromes, mutually intertwining with them.. At the very be­ginning symptoms become of wide demention and fabulousness. In such cases the result is most often a so-called "active" (2) or "positive" (9) variant of psychic automatism. It can be definitely sald that the syndrome of psychic automatism is one of the richest syn­dromes concerning phenomenology affecting almost all the psychic spheres. Its presence in the clinical course of psychosis must always suggest the diagnosis "schizophrenia" although in li­terature available a number of cases are reported of the syndrome of psychic automatism de­tected in exogenous-organic, the rest endogenic and even in some psychogenic psychoses. It is undoubted that elements (symptoms) of this syndrome can be detected in other psychoses, too. However, in our opinion, in schizophrenia only the syndrome can be found out in completed and full aspect. Of course, this statement is not a new one. It is known that K. Schneider (1957) directed from purely clinico-pragmatic considerations in his diagnostic approach to schizophrenia, differentiates a group of symptoms with different discrimination value and calls them symptoms of 1 s t rank and symptoms of 2nd o n e (symp­toms of 3r(* rank can be considered so-called abnormal ways of behavirour and expression ("Ausdruckssymptome"). Symptoms of 1 s t rank (a total of 12 ones) are schizophrenia-speci­fic. It has to be noted that almost all the symptoms of this group are included into the syndro­me of psychic automatism whose symptomatology is incomparably much more abundant and reflects pathological events in their dynamics. It is of no accident that in СATEGO programme (16) widely used for computer-alded diagnosis in WHO studies, a so-called core syndrome is formed extraordinarily on the basis of psychic automatism (symptoms of 1 s t rank after K. Schneider, respectively). Core syndrome presence in the clinical picture of the psychosis is the main criterion to relate this clinical picture to class "S" in the programme. Diagnostic class "S" comprises cases when psychiatrists from various countries and schools would diagnosticate as schizophrenia. Based on careful multinational investigations carried out by WHO A. Zhablen-ski's conclusion seems rather reasonable, namely "that core syndrome is highly schizophrenia-specific" and, therefore, it can present trustworthy support in the diagnosis of schizophrenia. When considering the syndrome of psychic automatism in clinical psychiatry one almost al­ways proceeds from clinico-pragmatical positions. Just from these positions psychic automat­ism is evaluated as schizophrenia-specific, core syndrome, on the one hand, and as unspecific syndrome occuring in the clinical picture of numerous different psychotic states,' on the other hand. However, clinico-theoretically, is not the syndrome of psychic automatism a reflection or a manifestation of the disturbance of unity of psychic experiences (i.e. of their split)? Does it not present a solid argument for its attaching to the basic schizophrenic disturbances? We think that these questions can be answered positively without trying to express an unidirectional ex­plicit standpoint. Concerning the clinical. 79 R E F E R E N C E S 1. А н у ф р и е в , А. К.Ж. невропатол. и психиатр., 1979, № 9 , 1397-1405. - 2. Г у л я м о в, M. Г., Ж. невропатол. и психиатр., 1972, № 12, 1847-1851. - 3. Ж а б л е н с к и . А . Шизофрения - нозоло-гично единство и културово многообразие. София, Медицина и физкултура, 1986. - 4. К а н д и н-с к и й, В. X. О псевдогаллюцинациях. Москва, 1952. - 5. М е г р а б я н, А. А. Деперсонализация. Ереван, 1962. - 6. М е г р а б я н, А. А. Общая психопатология. Москва, 1972. - 7. П е р е л ь м а н , А. А. Ж. невропатол. и психиатр., 1931, № 3, 44-53 . - 8. С н е ж н е в с к и й , А . В. Руководство по психиатрии. Т. 1. Москва, 1983, с. 70. - 9. X а л е ц к и й, А. М. Ж. невропатол. и психиатр., 1974, №2, 261-264. - 10. В a i 1 1 а r r , J . Ann. med. psychol., 7, 1846, No 1, 1-12. - И . С е i 11 ie г, A L'En-cephale, 1927, Mo 4, 273-297. - 12. С 1 e г a m b a u lt, G. d е. L'automatisme mental. Т. I I . Paris, P U F , 1942, 528-529. - 13. J a n е t,P. L'automatisme psychologique. Paris, 1889. - 14. S с h n е i d е r, K. Fo*+-schr. Neurol u. Psychiatr., 9, 1957, 487-490. - 15. S е g l a s, J . Progres med., Prais, 16,1888, p. 53. - 15. W i n g , J . , J . C o o p e r , N. S a r t o r i u s . The measurement and classification of psychiatric symptoms. Cambridge, Cambridge University Press, 1974. К ВОПРОСУ О КЛИНИЧЕСКОЙ ЗНАЧИМОСТИ СИНДРОМА ПСИХИЧЕСКОГО АВТОМАТИЗМА С. Тодоров, А. Димитрова, Е. Дамянова, В. Чакаловс Р Е З Ю М Е Синдром психического автоматизма является одним из часто встречающихся синдромов в пси­хопатологии. Во многих отношениях однако его клиническая значимость охарактеризована не сов­сем ясно. Опираясь на литературные данные и на собственные исследования, охватывающие 140 больных шизофренией с синдромом психического автоматизма, авторы рассматривают этот вопрос в общепсихопатологическом, а также и в клинико-нозологическом планах. В общепсихопатологи­ческом плане указывается на обстоятельство, что деперсонализация и „отчуждение" не должны отож­дествляться с синдромом психического автоматизма, несмотря на то, что они находятся в очень сложных взаимоотношениях с частыми совпадениями. В клинико-нозологическом плане синдром психического автоматизма рассматривается как расщепление единства психических переживаний, а оттуда - как ,,ядерный" симпотом шизофренного психоза. 

CONCERNING THE CLINICAL SIGNIFICANCE OF THE SYNDROME OF PSYCHIC AUTOMATISM

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CONCERNING THE CLINICAL SIGNIFICANCE OF THE SYNDROME OF PSYCHIC AUTOMATISM

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