French perspectives on psychiatric classification

Abstract

This article reviews the role of the French schools in the development of psychiatric nosology. Boissier de Sauvages published the first French treatise on medical nosology in 1763. Until the 1880s, French schools held a pre-eminent position in the development of psychiatric concepts. From the 1880s until World War I, German-speaking schools exerted the most influence, featuring the work of major figures such as Emil Kraepelin and Eugen Bleuler. French schools were probably hampered by excessive administrative and cultural centralization. Between the 1880s and the 1930s, French schools developed diagnostic categories that set them apart from international classifications. The main examples are Bouffée Délirante, and the complex set of chronic delusional psychoses (CDPs), including chronic hallucinatory psychosis. CDPs were distinguished from schizophrenia by the lack of cognitive deterioration during evolution. Modern French psychiatry is now coming into line with international classification, such as DSM-5 and the upcoming ICD-11.

Introduction

This article reviews the contributions of French schools to the development of psychiatric nosology. Briefly, French psychiatry enjoyed a pre-eminent position in the development of psychiatric nosology until the 1880s. From the 1880s until World War I, German-speaking schools exerted the most influence, with the contributions of giants such as Emil Kraepelin and Eugen Bleuler. In the 20th century, English established itself as the sole international scientific language—a development which was met with unease in France. In addition, the best conditions for research funding were in the United States. Another important determining factor in the development of French schools is a degree of administrative and cultural centralization that exceeds what is observed in most other western countries. Due to limited space, this article cannot offer an exhaustive historical account; it will instead focus on key historical conjunctures.

From the classical era to the Enlightenment

The first famous French medical nosology treatise, by Francois Boissier de Sauvages (1706-1767), was published at a time when Latin was the language of medical science. In keeping with the scientific Zeitgeist, it was inspired by botanical nosology. It was thought that illnesses were natural species that could be classified in the same way as plants.¹Francois Boissier de Sauvages studied medicine and botany at the university of Montpellier. He corresponded with the Swedish naturalist Carl von Linne and sent him botanical specimens. In 1763, he published his famous Nosologia methodica. The nosology was published in Latin, and a French translation of this nosology appeared only posthumously in 1772.² On the very title page of his book, Boissier de Sauvages proclaimed that his nosology was constructed “in the spirit of Sydenham and with the methods of the botanists.” He referred to the clinical observation method of Thomas Sydenham (1624-1689), and to the botanical classification of Linne. Accordingly, Boissier de Sauvages's classification system listed 10 major classes of disease, which were further broken down into orders, genera, and 2400 species (individual diseases). Mental disorders, Vesaniae, belonged to the 8th class of diseases, which comprised four orders: (i) Hallucinations, subdivided into Vertigo, Suffusion, Diplopia, Syrigmus (ie, imaginary noise perceived in the ear), Hypochondriasis, and Somnambulism; (ii) Morositates, further subdivided into Pica, Bulimia, Polydipsia, Antipathia, Nostalgia, Panophobia (ie, panic terror), Satyriasis, Nymphomania, Tarantism (ie, immoderate craving for dance), and Hydrophobia; (iii) Deliria, subdivided into Paraphrosine (ie, temporary delirium caused by a substance or a medical illness), Amentia (“universal” delirium without furor); Melancholia (“partial” and nonaggressive delirium with sadness and chronicity), Mania (“universal delirium” with furor and chronicity), Demonomania (ie, melancholia attributed to the devil); and (iv) Folies anomales comprising Amnesia, and Agrypnia (ie, insomnia). At first glance, Boissier de Sauvages' classification looks like an antiquated hodge-podge. In reality, when the diagnostic terms are translated into their modern equivalents, it appears that Boissier de Sauvages' classification shares similarities with modern classifications. An effort is made to group disorders into chapters on the basis of common mechanisms or symptoms (hallucinations, or delusions). A few other illnesses reflect fads that happened to be common expressions of mental suffering at a particular time in a specific culture (eg, tarantism). It is worth noting that the Greek word “mania” is usually associated with its Latin translation, furor. The term “delirium,” in this context, designates delusional states. Tarantism (the etymology of the word is the town Taranto) was a frequently mentioned condition in medical treatises at the time. It designated a craving for dance and music that occurred epidemically in Southern Italy from the 15th to the 17th century and was attributed to the effects of a tarantula spider bite; Boissier de Sauvages mentions that differential diagnoses of tarantism should take into account hysteria, nymphomania, and malingering by nuns who wished to go to dances. The distinction between “universal” and “partial” delusions employed by Boissier de Sauvages was to have a long history in French psychiatry; it would resurface in Esquirol's monomanias and the subtypes of chronic systematized delusional disorders in the 20th century.

The Encyclopedie, the encyclopedia of arts and sciences edited by Diderot and d'Alembert between 1751 and 1772, reflected the state of scientific knowledge in the French-speaking world during the period of Enlightenment in the late 18th century. The Encyclopedie is often hailed as a symbol of the Enlightenment, a liberation of the mind and a casting off of old molds that heralded the French revolution. Two physicians, both educated at the medical school of Montpellier, wrote the articles on medical matters in the Encyclopedia: Arnuiphe d'Aumont (1721-1800) (up until volume 7), and Jean-Joseph Menuret (1733-1815) (from volume 8). D'Aumont spent his professional life in Valence (in the Drome departement in the southern Rhone valley), whereas Menuret eventually moved to Paris. This geographical move reflects an important fact in the history of French science. Whereas Montpellier housed the oldest medical school in France, a process of administrative centralization in Paris started with the French revolution and was reinforced by Napoleon. The effect of this centralization on the fate of French psychiatric schools in the 19th century was formulated with keen perception by Edward Shorter³(who has contributed an article to this issue of Dialogues in Clinical Neuroscience on the development of DSM, p 59):

Only in France could a handful of chair-holders in Paris dominate the destiny of medical training in a country of almost 40 million people. When a system like the French one produces a Pasteur, its extreme centralization has the potential to mobilize large amounts of talents. When it produces someone like Charcot, quite lacking in common sense and grandiosely sure of his own judgment, it harbors the potential for calamity.

In the Encyclopedia, the article on Délire (delusion) expounds a sort of nosology, complete with subtypes and etiological hypotheses. Délire is defined as a state occurring in a waking condition, whereby things known to be common knowledge are judged wrongly.⁴The general etiology of Délire is supposed to lie in a faulty functioning of brain fibers, and its subtypes are based on different etiological mechanisms: (i) Manie or Phrenesie may occur when all brain fibers are too tense (thus, it is a “universal” delusional state); (ii) Demonomanie or Melancolie occur if only a few brain fibers are excessively tense (it is a “partial” delusional state); (iii) Lethargie or Stupidite happen when the brain fibers are too lax. Demonomanie is a variant of Melancolie where the patients have the belief of being possessed by demons. Based on the clinical features, Roselyne Rey⁵proposed a nosology of various types of délires in the Encyclopedie (Table I).

Table I. Classification of délires (delusional states) in the Encyclopédia. Adapted from ref 5: Rey R. La pathologie mentale dans l'Encyclopédie: définitions et distribution nosologique. In: Recherches sur Diderot et sur l'Encyclopédie. 1989;7:51-70. Copyright© Société Diderot 1989.

		Moderate	Furor	Paroxystic
No fever	Partial délire (delusion)	Mélancolie (melancholia)
	Universal délire	Folie (Imbécilité) (madness-imbecility)	Manie (mania)	Rage
Fever		Léthargie (Délires obscurs) (lethargy-obscure delusion)	Phrénésie (phrenesis)

The founders of modern French psychiatric nosology—the glorious 19th century

A new cultural era was inaugurated by the French Revolution. Emblematic figures at this time were Philippe Pinel and his pupil Esquirol. Philippe Pinel (1745-1826) studied medicine at the faculties of Toulouse and Montpellier and arrived in Paris in 1778. He was sympathetic with the ideas of the French revolution and he obtained his first appointment to Hopital Bicetre in 1793, the year when Robespierre's terror would be unleashed. He moved to a position at Hopital Salpetriere in 1795. Pinel translated the works of William Cullen, which influenced him for his own nosology.⁶Pinel became established as a nosologist with the publication of the Nosographie philosophique in 1798.⁷Pinel is depicted in a painting and statue as ordering the removal of the chains of mental patients. He used the term neurosis, borrowed from Cullen. However, his nosology smacks of the classification and the terminology of Boissier de Sauvages, and it seems still grounded in the 18th century. Following botanical principles, illnesses are still grouped into classes, which comprise several orders. The first class of illnesses is entitled “neuroses,” with four orders. The first order, “sensory neuroses,” is a heterogeneous collection of disorders that may be organic (eg, diplopia or deafness) or hallucinatory. The second order includes mental, neurological, and cerebrovascular disorders such as melancholia and mania; dementia and idiotism; stroke and epilepsy. The third disorder, termed locomotor neuroses, includes tetanus, seizures, etc. The fourth order, termed neuroses of nutrition, is further subdivided into digestive neuroses (eg, bulimia, pica), respiratory neuroses (eg, asthma, whooping cough), and circulation neuroses (eg, syncope).

Jean-Etienne Dominique Esquirol (Toulouse, 1772-Paris, 1840) is a key figure in the history of psychiatric nosology because he coined several diagnostic terms, and advocated the use of statistics as a tool for research. According to Edward Shorter, Esquirol “really represents the beginning of all classification in psychiatry.”⁸Esquirol studied over 4 years (1811-1814) the rate of admissions of patients with melancholia to the hospital Salpêtrière in Paris. Thus, he established a seasonal pattern with a larger number of admissions between the months of May and August. The several diagnostic terms that Esquirol coined had various degrees of success. He introduced the term lypomania as a replacement for the word melancholia, which was felt to have lost precision because of overuse. He introduced the term monomania, to describe all kinds of delusional states focused on a single theme. One of the monomanias that Esquirol first described is erotomania.

A psychiatrist who was forgotten and recently rediscovered is Louis-Victor Marce (1828-1864). According to some authors, he may have been one of the most innovative psychiatrists of the 19th century.⁹ He described anorexia nervosa, before the articles published in 1873 by William Gull in England and Ernest-Charles Lasegue about this condition.¹⁰ Marce published a treatise on mental illnesses in 1862.¹¹ In this treatise (p 50 onwards) Marce expounds in a modern way the principles of psychiatric classification. He committed suicide at the age of 37 in a state of melancholia. Marce's father had a history of psychiatric treatment, and Marce himself may have suffered from bipolar disorder.

A remarkable psychiatric journal, Les Annales Medico-Psychologiques, was founded in 1843, shortly after Esquirol's death. It is thought to be one of the earliest psychiatric journals, and one of the oldest in continuous existence. At the end of the 19th century, French articles still exerted a powerful impact. A good example is provided by the history of the term “anhedonie/anhedonia.” Theodule Ribot (1839-1916) introduced this term in 1896 in his book, La Psychologic des Sentiments.¹² Ribot explained that he coined this term to designate the absence of pleasure based on the model of the word analgesia, meaning absence of pain. This neologism associated the Greek privative prefix αv- (an-) with the Greek word for pleasure (ηδovη [hêdonê]). For Ribot, “anhedonie” designated a specific type of depression characterized by a passive lack of joy, a loss of enjoyment and desire. Ribot's neologism enjoyed rapid success in English-speaking literature. According to the Oxford English Dictionary, the first occurrence of the word anhedonia is in the English translation of Ribot's book,¹³in 1897, only 1 year after the French publication. William James, in the United States, adopted this term in 1902, attributing the coining of the term to Ribot. The American psychiatrist Abraham Myerson did the same in 1922. In current international diagnostic classifications, anhedonia, defined as absence of pleasure or loss of interest, belongs to the two (DSM-5) or three (ICD-10) key criteria of depression.

From the fin de siècle to the interwar period—bouffées délirantes and chronic delusional psychoses

The 1880s were the turning point at which the predominant position of French schools in psychiatry was eclipsed by Germany. Many reasons have been put forward to account for the decline of French psychiatry and the rising preeminence of the German schools. One first hypothesis is excessive centralization in the domain of administration, teaching, and culture. In 19th-century France, almost all of the psychiatric treatises were published by heads of departments in a few famous Parisian hospitals (eg, Salpêtrière, Bicetre). In contrast, culture and major universities were not centralized in Germany. According to Pichot, ),¹⁴ in 1880 there were 19 chairs of psychiatry in different cities across Germany, whereas France had only one chair of psychiatry, and that was in Paris! The exact count of chairs may be complicated, depending on whether German-speaking chairs outside Germany are included. Other hypotheses have pointed to differences in the general rate of economic developments, with prosperous periods in France in 1850-1870 and in Germany between 1880 and 1900. In a way, the French system came under the shadow of Kraepelin, whose influence began to spread beyond Germany's borders. This sparked nosological constructions that can be seen as a reaction to the German system. Eventually, French nosology developed a few diagnostic categories that set it apart from international psychiatric nosology, for instance bouffées délirantes and the complex system of chronic delusional psychoses.

A pivotal figure in the classification of mental diseases in France during this period of transition is Valentin Magnan (1835-1916).¹⁵ The diagnostic category of bouffée délirante was first described by Magnan in the 1880s. It referred to psychotic episodes of good prognosis, not connected with schizophrenia, appearing in a particular type of fragile personality.¹⁶

For most of the 20th century, French nosology limited the scope of schizophrenia to the chronic delusional psychoses, and bouffée délirante.¹⁷ Up until the advent of DSM-III in the 1980s, the grouping of chronic delusional psychoses (CDP, psychoses délirantes chroniques) was an important chapter in French psychiatric nosology. In a way, CDPs were a resistance to Kraepelin's dementia praecox. CDPs were differentiated from schizophrenia by several features. First, they were characterized by the absence of either negative or cognitive symptoms. In French textbooks, that was expressed as the absence of “schizophrenic dissociation” (dissociation, originally a translation from the German Spaltung, came to correspond largely to the English term “disorganization” in the context of schizophrenia). CDPs were observed in individuals whose personality and functioning were seemingly normal. In contrast, patients with schizophrenia showed a typical syndrome termed discordance that was defined by the fact that the individual was ambivalent, bizarre, impenetrable, and withdrawn. Second, CDPs did not evolve toward cognitive deterioration, social withdrawal, or dementia praecox. The absence of evolution toward deterioration was in fact the key criterion in the differential diagnosis between CDPs and paranoid schizophrenia. Third, the various types of chronic delusional disorders were distinguished from one another and subclassified on the basis of their delusional “mechanisms,” ie, whether the patient's symptoms were caused by delusions or faulty interpretations, hallucinations, or imagination. Table II shows the French classification of chronic delusional disorders, on the basis of the elaborate description and synthesis made by Henri Ey (1900-1977).¹⁸ Henri Ey was born in Roussillon, and had a good knowledge of Catalan and Spanish culture. He spent most of his career at the hospital in Bonneval, a small city near Chartres and llliers-Combray (the city made famous by Proust's novel, In Search of Lost Time). Henri Ey's textbook remained the main reference for young French doctors preparing for psychiatric examinations, until DSM-III permeated French psychiatry. The classification in Table II may differ slightly from the organization of French chronic delusional states expounded in Edward Shorter's Historical Dictionary of Psychiatry. This is due to the fact that the French classification of CDPs was never definitively established, but rather varied with each successive French-language textbook of psychiatry. Successive textbooks strove to put together diagnostic categories described by previous authors such as Serieux and Capgras,¹⁹ Ernest Dupre,²⁰ de Clerambault,²¹ and many others, with the result that the whole nosological construction was like trying to erect an edifice with construction blocks borrowed from diverse architectural periods. In the textbook written by Joseph Levy-Vaiensi (1879-1943),²² the chronic hallucinatory psychoses and the systematized delusional disorders related to paranoia are two distinct chapters, while these entities are grouped in the same chapter in Henri Ey's textbook. Levy-Valensi, a historian of psychiatry, was the successor of Henri Claude (1869-1945) at the chair in Sainte-Anne, but his career was cut short by his death at Auschwitz; his daughter recounted in an interview that he carried with him a letter signed by Marshal Petain stating “Messieurs les Allemands, this man is a great Frenchman, do not touch him.”

Table II. Classification of chronic delusional psychoses in the French school of psychiatry in the first half of the 20th century. Adapted from ref 5: Ey H, Bernard P, Brisset C. Manuel de psychiatrie. Paris, France: Masson; 1978:506-533. Copyright © Masson 1978.

Diagnostic categories	Subtypes	Authors	Key features
	Delusional claimants (litigators; discoverers; passionate idealists) Délires de revendication (quérulents processifs; inventeurs; idéalistes passionnés)	G. G. de Clérambault	A delusional state develops, as a delusional “sector” wedged into reality, on the basis of a paranoid predisposi-tion. The delusional system is organized around one initial delusional postulate. Reality testing is intact. Emotional exaltation, hypersthenia
Chronic systematized delusional disorders (paranoia) Délires chroniques systématisés (paranoïa)	Passionate delusions (erotomania; delusional jealousy) Délires passionnels (érotomanie, jalousie)
	Delusional sensitivity in inter-personal relationships Délire sensitif de relation	Related to Kretschmer's Beziehungswahn	Hyposthenia
	Delusional thinking Délire d'interprétation	Sérieux & Capgras. Concept related to Wahnwahrnehmung, and to Esquirol's intellectual monomany	Delusional reasoning, deductions or inductions. The patients interpret normal perceptions, according to a systematic delusional system that may develop as a “network.” No hallucinations, no querulancy; no evolution toward dementia
Chronic hallucinatory psychosis Psychose hallucinatoire chronique		G. Ballet. G. G. de Clérambault (automatisme mental)	Hallucinations (auditory, sensory, somatic)
Fantastic psychoses Psychoses fantastiques		Dupré. Concept related to Kraepelin's paraphrenias	“Imagination” is the main delusional mechanism

CDPs find their origin in the concept of folies partielles (partial madness) for which Esquirol coined the term monomania. Hie concept was subsequently amplified and developed, with many subtypes, in the treatises of many French psychiatrists, between the last decades of the 19th century and the first decades of the 20th century. In international classifications, some of these CDPs, notably CFIP, would be subsumed under schizophrenia, paranoid type, or late-onset schizophrenia; other CDPs, notably the various types of paranoia, would correspond to the delusional disorders of DSM. Bouffée délirante describes an acute nonaffective and nonschizophrenic psychotic disorder, which is largely similar to the DSM-5 brief psychotic and schizophreniform disorders, and to ICD-10's acute polymorphic psychotic disorder.

It is worth describing in more detail the specific diagnostic category of CHP because it is the one that perdured longer within the large ensemble of CDPs. The term “chronic hallucinatory psychoses” was created in 1907 by Ernest Dupre (1862-1921) and used again in 1911, in the singular, to describe a distinct nosological entity by Gilbert Ballet (1853-1916). Gilbert Ballet opposed Kraepelin and argued that CHP was not a paranoid form of dementia praecox, since early dementia was lacking in CHP. Successive French psychiatrists developed slightly modified theories of CHP. Gaetan Gatian de Clerambault (1872-1934) developed his own etiopathogenic theory of CHP. It is worth noting that chronic hallucinatory psychosis came to be defined by a mechanism termed “mental automatism,” described by de Clerambault.²³ The Russian psychiatrist Kandisky, who personally suffered psychotic episodes, also described this syndrome, which is therefore often referred to as the Clerambault-Kandisky syndrome.²⁴ Both de Clerambault and Kandisky committed suicide. The concept of mental automatism was used in France in clinical description, but its use has decreased in the last decades. Mental automatism refers to the enforced perception of ideas and voices in the brain (automatisme ideo-verbal): sensorial and sensory perceptions (automatisme sensorial et sensitive); and enforced movements in the muscle or speech organs (automatisme psychomoteur) . The patient develops the persecutory feeling of being alienated from his or her personal mental processes, and of being physically and mentally influenced by external forces. It is worth noting that the mental phenomena described as typical of the ideational-verbal automatism (own thoughts being broadcast, read by others, or heard as an echo; hearing commentaries on the subject's actions and thoughts) are in fact very similar to Schneider's first-rank symptoms that were important for criteria A of schizophrenia from DSM-III to DSM-IV. Clerambault's initial description sometimes lacks clarity; it is not always easy to understand.

Conclusion: coming to terms with international classifications

The official psychiatric classification in France is ICD-10. ICD-10 will soon to be replaced by ICD-11, whose structure and organization will show many similarities to DSM-5.²⁵ ICD is mostly used when coding diagnoses for administrative purposes. De facto, the material used nowadays for teaching students in France is largely derived from DSM. An independent classification has been proposed by a group of French child psychiatrists (GET ME A: French. Classification of Child and Adolescent Mental Disorders). The CFTMEA R 2012, a revision published in 2012, offers a large compatibility with ICD-10.²⁶ The introduction of DSM-5 has sparked the publication of many critical books in France.²⁷ The degree of active involvement in the preparation of DSM-5 varied across Western countries. It is worth noting that the list of DSM-5 Work Group members shows only one French member (Marc Auriacombe, a specialist in addiction from Bordeaux), as compared with seven members from the United Kingdom, six each from Canada and the Netherlands, and four from Germany.