Carl Jung was one of Freud’s earliest supporters and in many respects rivaled him in terms of influence. Some of their interactions provide the basis for the story behind the book and recent movie – A Dangerous Method. Just as Freud did, he famously analyzed himself and while doing so apparently became psychotic. His psychosis was however seen as a way to sanity – a forerunner of 1960s thinking about psychosis. It was also viewed in semi-spiritual terms.
This was all of interest when we came to explore another condition we found in the North Wales hospital records, a condition that made us keenly aware we were playing with fire. Against the background of a major strike in the quarries and mines of North Wales, in the autumn of 1904 and through to the summer of 1905, a preacher called Evan Roberts toured Wales stimulating the Great Revival – and stimulating into madness some of those who gathered in North Wales to hear him preach. There was a spike of admissions to the Asylum for psychoses that looked like schizophrenia or bipolar disorder (see Linden et al 2010).
Fire from Heaven
There is a well-known condition – Jerusalem syndrome, which affects Christians who go to the Holy Land. They go mad, but no-one knows what happens to them because they are sent home to the 4 corners of the globe. But we know what happened in 1905 because our patients had nowhere else to go. What happened was that they recovered and did not become unwell again. Today if recognized, these conditions can be called acute and transient psychoses in Europe and brief reactive psychoses in North America.
If recognized. Today a schizophreniform psychosis is likely to lead to a diagnosis of schizophrenia and treatment with antipsychotics for life. Or if the admission has a manic flavor, North American clinicians are obliged by DSM to diagnose a bipolar disorder, which is a sentence to a life of “mood-stabilizers”.
We ran into trouble with our article on religious psychoses – there were many in North Wales who read the research as critical of religion. Stay away we were warned darkly. This caught us completely by surprise. At the time the paper was being written, Lehman’s Brothers was collapsing and the threat of a Great Depression was very real. We saw the religious fervor of 1905, allied to the stress of a general strike, as producing the kind of conditions that any society can throw up from time to time, and that any of us can generate in our personal lives.
These are the patients who recover
One of currently fashionable ideas is Recovery. We are all supposed to have a recovery orientation. And of course it is helpful always to see the person rather than just the illness, but repeating this mantra is often aspirational rather than useful. These are the patients with psychoses who recover – who need to be recognized.
An important message from the historical record is that these patients recover without drug treatment. The worry today is that they will be slapped on medication and will be unable to get off it because of physical dependence or unhelpful advice from the mental health services that they have schizophrenia or bipolar disorder and need to remain on treatment for life.
These are the patients who now often give clinicians the impression that treatments work well, when in fact they were likely to recover anyway, and the real risk is they will be kept on treatments they don’t need. Is there any harm in staying on an antipsychotic just in case? Well in our data, older patients with acute and transient psychoses are particularly prone to heart attacks and strokes – much more so than younger patients with schizophrenia.
The once and future psychoses
When the asylums opened in the early nineteenth century, there were few if any cases of schizophrenia. Patients with psychoses who were admitted recovered and asylums were institutions geared toward recovery by giving patients a structured daily routine and opportunities for work on the farm and other activities. They were not the warehouses they later became when schizophrenia emerged. If schizophrenia – chronic psychosis – were to vanish, these brief reactive psychoses would be psychoses that are left. But these schizophreniform psychoses are a disorder that we barely understand. There are vanishingly few case series published to give us even the average age of onset or gender ratio of the patients affected. The biggest studies there are have 40 or so patients. Our databases contain hundreds of cases.
In this mix there may be psychogenic psychoses – mental rather than physical disorders. This may be something like the condition Jung induced in himself that many see he portrayed as a semi-spiritual state or stage of growth. There may be other personality based conditions. Yet other brief psychoses may be more physical in nature but still open to recovery.
These are conditions we need to learn more about because as we shall see in our records it looks like schizophrenia or at least chronicity is vanishing, and we are going to have to re-orient our services much more toward recovery than before.