Psychosis

Psychosis (pronounced sahy-koh-sis)

In psychiatry, a severe mental disorder (sometimes with physical damage to the brain), more serious than neurosis, characterized by disorganized thought processes, disorientation in time and space, hallucinations, delusions and a disconnection from reality.  Paranoia, manic depression, megalomania, and schizophrenia are all psychoses.

1847: From the New Latin & Late Greek psȳ́chōsis, the construct being psycho- + -osis, the source being the Ancient Greek ψύχωσις (psúkhōsis) (animation, principle of life), psych from the Ancient Greek ψυχή (psukhḗ or psykhē) (mind, life, soul).  The suffix –osis is from the Ancient Greek -ωσις (-ōsis) (state, abnormal condition or action), from -όω (-óō) (stem verbs) + -σις (-sis); -oses was the plural form and corresponding adjectives are formed using –otic, thus respectively producing psychoses and psychotic.  The Ancient Greek psykhosis meant "a giving of life; animation; principle of life".  In English, the original 1847 construction meant "mental affection or derangement" while the adjective psychotic (of or pertaining to psychosis) dates from 1889, coined from psychosis, on the model of neurotic/neurosis and ultimately from the Ancient Greek psykhē (understanding, the mind (as the seat of thought), faculty of reason).

In clinical use there are many derived forms (with meanings more precise than is often the case when such words migrate to general use) including antipsychotic, micropsychotic, neuropsychotic, nonpsychotic, postpsychotic, prepsychotic, propsychotic, protopsychotic, quasipsychotic, semipsychotic & unpsychotic.  The useful portmanteau word sarchotic (the construct a blend of sarcastic +‎ psychotic) is used to describe a statement so distrubingly sarcastic it can't be certain if the remark is intended to be humerous or the person making it genuinely is psychotic and even then there are graduations for which the adverb is used, the comparative being "more psychotically" and the superlative "most psychotically".  Psychosis & psychoticism are nouns, psychotic is a noun & adjective and psychotically is an adverb; the noun plural is psychoses.

Psychosis and the DSM

The word psychosis was a mid-nineteenth century creation necessitated by early psychiatry’s separation of psychiatric conditions from neurological disorders.  Originally a generalized concept to refer to psychiatric disorders, gradually it became one of the major classes of mental illness, assumed to be the result of a disease process, and, more recently, to a symptom present in many psychiatric disorders.  During this evolution, the diagnostic criteria shifted from the severity of the clinical manifestations and the degree of impairment in social functioning to the presence of one or more symptoms in a set of psychopathological symptoms.  By the early twentieth century, the concept of neurosis (which once embraced both the psychiatric and the neurological disorders), became restricted to one major class of psychiatric disease whereas psychosis (which once embraced all psychiatric disorders) became restricted to the other.

The first consensus-based classification with a description of diagnostic terms was in the first edition (DSM-I (1952)) of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) in which mental disorders were divided into two classes of illness: (1) organic disorders, caused by or associated with impairment of brain tissue function; and (2) disorders of psychogenic origin without clearly defined physical cause or structural changes in the brain.  When DSM-II (1968) was released, the classifications were revised with mental disorders now classed as (1) psychoses and (2) neuroses, personality disorders, and other non-psychotic mental disorders.  Psychosis was defined as a mental disorder in which mental functioning is impaired to the degree that it interferes with the patient's ability to meet the ordinary demands of life and recognize reality.

Advances in both neurology and psychiatry led to an extensive revision in DSM-III (1980).  Radically, all traditional dichotomies (organic versus functional, psychotic versus neurotic etc) were discarded with psychiatric syndromes assigned to one of fifteen categories of disease.  At the labelling level, the term psychotic was used to describe a patient at a given time, or a mental disorder in which at some time during its course, all patients evaluate incorrectly the accuracy of their perceptions and thoughts but the editors emphasized it should not be applied to patients suffering only minor distortions of reality, regardless of how exactly they might fulfil the clinical criteria.  The revisions in DSM-III-R (1987) extended only to slight changes in terminology.

Mirroring the changes in diagnostic criteria published by the WHO, DSM-IV (1994) noted the diagnosis of psychosis should no longer be based on the severity of the functional impairment but rather on the presence of certain symptoms which included delusions, hallucinations, disorganized speech and grossly disorganized or catatonic behavior.  This emphasis on psychoses being spectrum conditions was continued in DSM-5 (2013) with schizoid (personality) disorder and schizophrenia defining its mild and severe ends.  Additionally, a more precise diagnostic framework was defined in which patients were assessed in terms both of symptoms and duration of suffering.

Two examples of "schizophrenia art".

My Eyes in the Time of Apparition (1913) by August Natterer (1868-1938).

The life of German artist August Natterer began innocuously enough, studying engineering, travelling extensively, marrying and building a successful career as an electrician.  However, in his thirties, he began to experience anxiety attacks and delusions and in 1907 suffered a hallucination in which thousands of images flashed before his eyes in little more than thirty minutes.  So affected by the experience that he attempted suicide, he was admitted to an asylum and would spend the remaining quarter-century of his life in and out of institutes for the insane.  In the literature, Natterer is referred to as Neter, a pseudonym used by his psychiatrist to protect patient and family from the social stigma then associated with mental illness.  He described the 1907 hallucination as a vision of the Last Judgment which he described as:

"...10,000 images flashed by in half an hour.  I saw a white spot in the clouds absolutely close – all the clouds paused – then the white spot departed and stood all the time like a board in the sky. On the same board or the screen or stage now images as quick as a flash followed each other, about 10,000 in half an hour… God himself occurred, the witch, who created the world – in between worldly visions: images of war, continents, memorials, castles, beautiful castles, just the glory of the world – but all of this to see in supernal images. They were at least twenty meters big, clear to observe, almost without color like photographs… The images were epiphanies of the Last Judgment. Christ couldn't fulfil the salvation because he was crucified early... God revealed them to me to accomplish the salvation."

After his suicide attempt and committal to the first of what would be several mental asylums, Natterer thereafter maintained that he was the illegitimate child of Emperor Napoleon I (Napoleon Bonaparte (1769–1821; leader of the French Republic 1799-1804 & Emperor of the French from 1804-1814 & 1815)) and "Redeemer of the World".  The vision inspired Natterer to a prolific production of drawings, all documenting images and ideas seen in the vision, one especially interesting to those studying psychosis and schizophrenia being My Eyes in the Time of Apparition (1913), two eyes bloodshot and wide-open eyes staring from the page.  The irises of the eyes do not match.

The Scream (1893), oil, tempera & paste on cardboard, by Edvard Munch (1863-1944), National Gallery of Norway.

Norwegian Edvard Munch was one of a number of artists modern psychiatrists have written of as having both genetic and environmental predispositions to mental illness, schizophrenia in particular; one of Munch’s sisters had schizophrenia, his father suffered from depression, his mother and another sister dying from tuberculosis when he was young.  Munch though was a realist, once telling an interviewer, “I cannot get rid of my illnesses, for there is a lot in my art that exists only because of them.”  The idea of affliction as a source or artistic inspiration appears often in the literature of art, music and such and in that it's something of a parallel with those who produce their finest work while living under political oppression; unpleasant as that can be, reform can see careers suffer, famous dissidents abruptly left as "rebels without a cause" after the fall of the Soviet Union (1922-1991) and a generation of the UK's activists found grist for their mills less prolific after the Tory Party had Margaret Thatcher (1925–2013; UK prime-minister 1979-1990) walk the political plank.  Where one door closes however, another sometimes opens and in John Major (b 1943; UK prime-minister 1990-1997) the comedians found a rich vein of material.    

His was a troubled life and in 1908, following a psychotic break exacerbated by alcoholism, Munch was admitted to a mental health clinic, later diagnosed with neurasthenia, a clinical condition now known to be closely associated with hypochondria and hysteria.  Adding to his problems, the Nazis labelled Munch’s style “degenerate art” and in 1937 confiscated many of his works but their disapprobation had less of an influence on his painting than his schizophrenia, his output continuing to feature figures obviously tortured by anguish and despair.  The apparently frantic strokes of the brush and his seemingly chaotic pallet of colors have long intrigued both critics and clinicians seeing insight into his state of mind, the idea being his paintings provide something of a visual representation of how schizophrenia might lead individuals to see the world.

Lindsay Lohan, following Edvard Munch, rendered by Vovsoft in comicbook style.

Endlessly reproduced, the subject of numerous memes and the inspiration for many re-interpretations, The Scream is Munch’s most famous work and the most emblematic of what now casually is called “schizophrenic art” (unfortunately often conflated with “art by schizophrenics”).  For decades it has been the chosen artistic representation for the angst-ridden modern human condition, the artist in 1890 noting in his diary a still vivid memory: “I was walking along the road with two friends—the sun went down—I felt a gust of melancholy—suddenly the sky turned a bloody red... I felt this big, infinite scream through nature.”  That entry was written some years after the sight and before painting The Scream in 1893 but the moment stayed with him because his vision of the sky caused him to “tremble with pain and angst” and he felt he heard his “…scream passing endlessly through the world.”  For historians those fragment of memory proved of interest and in his book Krakatoa:The Day the World Exploded (2003), detailing the 1883 eruption of the Indonesian volcano Krakatoa, Simon Winchester (b 1944) connected the “blood red” Norwegian sky with the fiery sunsets created by the ash from the explosion circulating the planet, high in the atmosphere.

Krakatoa: The Day the world exploded.

The idea of a link between the catastrophic geological event and the painting had long intrigued art historians who understood such a sight would have appeared “surreal”, decades before the surrealism movement became established and that it was a natural phenomenon is well-supported by theoretical modelling.  Between 20 May-21 October 1883, Krakatau, a volcanic island in the Sunda Strait, erupted, the “main event” happening on 27 August, during which over two-thirds of the island and its surrounding archipelago was destroyed, the remnants subsequently collapsing into a caldera (in volcanology, a large crater formed by collapse of the cone or edifice of a volcano).  The event created a large tsunami which, much diminished, reached the Atlantic and it’s believed that day’s third explosion was history’s loudest known sound.  What Edvard Munch is thought to have seen is the evening light of the sun being colored by the millions of tons of sulfur dioxide and volcanic dust blasted high into the atmosphere, circulating there for years including over Oslo when the artist was taking his walk.  Nor was he wholly wrong in suggesting “a scream passing” because such was energy generated by the explosion, the acoustic pressure wave circled the globe at least three times.

Asperger

Asperger (pronounced a-spuh-guh or a-spr-gr)

(1) In neo-paganism and modern witchcraft, a ceremonial bundle of herbs or a perforated object used to sprinkle water (in spells as “witches water”), usually at the commencement of a ritual.

(2) In neurology, as Asperger's syndrome (less commonly Asperger syndrome), an autism-related developmental disorder characterised by sustained impairment in social interaction and non-verbal communication and by repetitive behaviour as well as restricted interests and routines.  The condition was named after Austrian pediatrician Hans Asperger (1906–1980).

Pre-1300: The surname Asperger was of German origin and was toponymic (derived from a geographical location or feature).  The town of Asperg lies in what is now the district of Ludwigsburg, Baden-Württemberg, in south-west Germany and in German, appending the suffix “-er” can denote being “from a place”, Asperger thus deconstructs as “someone from Asperg” and in modern use would suggest ancestral ties to the town of Asperg or a similar-sounding locality.  Etymologically, Asperg may be derived from older Germanic or Latin roots, possibly meaning “rough hill” or “stony mountain” (the Latin asper meaning “rough” and the German berg meaning “mountain or hill”.  The term “Asperger’s syndrome” was in 1976 coined by English psychiatrist Lorna Wing (1928–2014), acknowledging the work of Austrian pediatrician Hans Asperger (1906–1980).  Dr Wing was instrumental in the creation of the National Autistic Society, a charity which has operated since 1962.  Asperger is a noun (capitalized if in any context used as a proper noun).  Aspergerian & Aspergic are nouns; the noun plural forms being Aspergers, Aspergerians & Aspergics.  In the literature, Aspergerian & Aspergic (of, related to, or having qualities similar to those of Asperger's syndrome (adjective) & (2) someone with Asperger's syndrome (noun)) appear both to have been used.  In general use “Asperger's” was the accepted ellipsis of Asperger's syndrome while the derogratory slang forms included Aspie, autie, aspie, sperg, sperglord & assburger, now all regarded as offensive in the same way “retard” is now proscribed.

The noun asperges described a sprinkling ritual of the Catholic Church, the name was applied also to an antiphon intoned or sung during the ceremony.  It was from the Late Latin asperges, noun use of second-person singular future indicative of aspergere (to scatter, strew upon, sprinkle), the construct being ad (to, towards, at) + spargere (to sprinkle).  The use in Church Latin was a learned borrowing from Latin aspergō (to scatter or strew something or someone; to splash over; to spot, stain, sully, asperse; besmirch; (figuratively) to bestow, bequeath something to, set apart for) the construct being ad- +‎ spargō (strew, scatter; sprinkle; moisten).  The origin lay in the phrase Asperges me, Domine, hyssopo et mundabor (Thou shalt sprinkle me, O Lord, with hyssop, and I shall be cleansed), from the 51^st Psalm (in the Vulgate), sung during the rite of sprinkling a congregation with holy water.  Hyssop (any of a number of aromatic bushy herbs) was from the Latin hȳsōpum, from the Ancient Greek ὕσσωπος (hússōpos), of Semitic origin and the idea was would be cleansed of one’s sins.  In the Old English the loan-translation of the Latin aspergere was onstregdan.

The three most recent popes demonstrate their aspergillum (also spelled aspergill) technique while performing the sprinkling rite.  In the more elaborate rituals, it's often used in conjunction with a container called an aspersorium (holy water bucket).  Benedict XVI (1927–2022; pope 2005-2013, pope emeritus 2013-2022, left), Francis (1936-2025; pope 2013-2025, centre) and Leo XIV (b 1955; pope since 2025, right).

In the Christian liturgy, an aspergillum was used to sprinkle holy water and the borrowing, adaptation and re-purposing of ceremonies, feasts days and such from paganism widely was practiced by the early Church.  In the Bible (notably chapter 14 in the Old Testament’s Book of Leviticus) there are descriptions of purification rituals involving the use of cedar wood, hyssop, and scarlet wool to create an instrument for sprinkling blood or water and historians sometimes cite this as “proto-aspergillum”.  While it seems the earliest known use on English of “aspergillum” dates from 1649, the documentary evidence is clear the practice in the Christian liturgy was ancient and common since at least the tenth century.  Exactly when the ritualistic practice began isn’t known but because water is so obviously something used “to cleanse”, it’s likely it has been a part of religious rituals for millennia before Christianity.

Asperger ceremonial herb bundle.

The use of the “asperger” in neo-paganism & witchcraft was a continuation of the concept and well documented in the remarkably prolific literature (some book shops have dedicated sections) devoted to modern witchcraft and the construction of the objects (a bundle of fresh herbs or a perforated object for sprinkling water) is a lineal descendent of the aspergillum of the Medieval church and that makes sense, both institutions devoted to the process of cleansing although the targets may have differed.  According to Ancient Pathways Witchcraft (which sounds an authoritative source), although it’s the fluid which does the cleansing, the asperger is significant because it symbolizes “the transformative and cleansing properties of water…”, rinsing away “…spiritual debris that might interfere with the sanctity of rituals.”  In both neo-paganism and witchcraft, the herbs used may vary and while, pragmatically, sometimes this was dictated by seasonal or geographical availability, priests and witches would also choose the composition based on some “unique essences” being better suited to “enhance the sacred water's effectiveness”.  Nor were herbs always used for, as in the rituals of the church, “an asperger might be a metal or wooden rod designed with perforations or an attached mesh”, something like a “small brush or a dedicated holy water sprinkler akin to those seen in Christian liturgy.”  Again, it was the sprinkling of the water which was the critical element in the process, the devices really delivery systems which, regardless of form, existed to transform simple water into “a divine medium of purity and transformation.”  That said, their history of use did vest them with tradition, especially when certain herbs were central to a spell.

Dr Hans Asperger at work, Children's Clinic, University of Vienna, circa 1935.

The term “Asperger’s syndrome” first appeared in a paper by English psychiatrist Lorna Wing (1928–2014) although use seems not to have entered the medical mainstream until 1981.  Dr Wing (who in 1962 was one of the founders of the charitable organization the National Autistic Society) named it after Austrian pediatrician Hans Asperger (1906–1980) who first described the condition in 1944, calling it autistischen psychopathen (autistic psychopathy).  Dr Wing was instrumental in the creation of the National Autistic Society, a charity which has operated since 1962.  The German autistischen was an inflection of autistisch (autistic), the construct being Autist (autistic) +‎ -isch (an adjectival suffix).

Dementia Praecox, oder Gruppe der Schizophrenien (1911) by Eugen Bleuler.

The English word autism was from the German Autismus, used in 1913 by Swiss psychiatrist and eugenicist Eugen Bleuler (1857-1939), the first known instance dating from 1907 and attributed by Swiss psychiatrist & psychotherapist Carl Jung (1875-1961) as an alternative to his earlier “auto-erotism” although in his book Dementia Praecox, oder Gruppe der Schizophrenien (Precocious Dementia, or Group of Schizophrenias, 1911) Bleuler differentiated the terms.  The construct of the word was the Ancient Greek αὐτός (autos) (self) + -ισμός (-ismós) (a suffix used to form abstract nouns of action, state or condition equivalent to “-ism”).  Being a time of rapid advances in the relatively new discipline of psychiatry, it was a time also of linguistic innovation, Dr Bleuler in a Berlin lecture in 1908 using the term “schizophrenia”, something he’d been using in Switzerland for a year to replace “dementia praecox”, coined by German psychiatrist Emil Kraepelin's (1856-1926).  What Dr Bleuler in 1913 meant by “autistic” was very different from the modern understanding in that to him it was a symptom of schizophrenia, not an identifiably separate condition.  In the UK, the profession picked this up and it was used to describe “a tendency to turn inward and become absorbed in one's own mental and emotional life, often at the expense of connection to the external world” while “autistic thinking” referred to those who were “self-absorbed, fantasy-driven, and detached from reality; thinking patterns, commonly seen in those suffering schizophrenia.”

Looking Up was the monthly newsletter of the International Autism Association and in Volume 4, Number 4 (2006), it was reported Lindsay Lohan’s car had blocked the drop-off point for Smashbox Cares, a charity devoted to teaching surfing to autistic youngsters.  Arriving at the designated spot at Malibu’s Carbon Beach, the volunteers were delayed in their attempt to disembark their charges, something of significance because routine and predictability is important to autistic people.  To make up for it, Ms Lohan staged an impromptu three hour beach party for the children, appearing as a bikini-clad DJ.  Apparently, it was enjoyed by all.

Autistic Disturbances of Affective Contact (1943) by Leo Kanner.

The modern sense of “autistic” began to emerge in the 1940s, among the first to contribute the Austrian-American psychiatrist Leo Kanner (1894–1981) who in 1943 published a paper using the phrase “early infantile autism” to describe a distinct syndrome (which now would be understood as autism spectrum disorder).  The following year, in Vienna, Dr Asperger wrote (seemingly influenced by earlier work in Russia) of his observational studies of children, listing the behaviors he associated with the disorder and unlike some working in the field during the 1940s, Dr Asperger wasn’t wholly pessimistic about his young patients, writing in Autistic Psychopathy in Childhood (1944): “The example of autism shows particularly well how even abnormal personalities can be capable of development and adjustment. Possibilities of social integration which one would never have dreamt of may arise in the course of development.”  Many of the documents associated with Dr Asperger’s work were lost (or possibly taken to the Soviet Union) in the chaotic last weeks of World War II (1939-1945) and it wasn’t until Dr Wing in the 1970s reviewed some material from the archives that his contributions began to be appreciated although not until 1992 did “Asperger’s Syndrome” became a standard diagnosis.

DSM IV (1994).  Not all in the profession approved of the reclassification of Asperger’s syndrome under the broader Autism Spectrum Disorder, believing it reduced the depth of diagnostic evaluation, flattened complexity and was disconnected from clinical reality.  There was also regret about structural changes, DSM-5 eliminating the multiaxial system (Axes I–V), which some clinicians found useful for organizing information about the patient, especially Axis II (personality disorders) and Axis V (Global Assessment of Functioning).

Asperger’s Syndrome first appeared in the American Psychiatric Association's (APA) classification system when it was added to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994) and the utility for clinicians was it created a sub-group of patients with autism but without a learning disability (ie characterized by deficits in social interaction and restricted interests, in the absence of significant language delay or cognitive impairment), something with obvious implications for treatment.  In the DSM-5 (2013), Autism Spectrum Disorder (ASD) was re-defined as a broader category which combined Asperger syndrome, Autistic Disorder & PDD-NOS (Pervasive Developmental Disorder Not Otherwise Specified) into a single ASD diagnosis, the editors explaining the change as a reflection of an enhanced understanding of the condition, the emphasis now on it being something with varying degrees of severity and presentation rather than distinct types.

However, although after 2013 the term no longer appeared in the DSM, it has remained in popular use, the British military historian Sir Antony Beevor (b 1946) in Ardennes 1944 (2015, an account of the so-called "Battle of the Bulge") speculating of Field Marshal Bernard Montgomery (First Viscount Montgomery of Alamein, 1887–1976) that "one might almost wonder whether [he] suffered from what today would be called high-functioning Asperger syndrome."  The eleventh release of the World Health Organization’s (WHO) International Classification of Diseases (ICD) (ICD-11) aligned with the DSM-5 and regards what once would have been diagnosed as Asperger’s Syndrome to be deemed a relatively mild manifestation of ASD.  The diagnostic criteria for ASD focus on deficits in social communication and interaction, as well as repetitive behaviors and interests.  Although no longer current, the DSM IV’s criteria for Asperger's Disorder remain of interest because while the label is no longer used, clinicians need still to distinguish those in the spectrum suffering some degree of learning disability and those not so affected:

DSM-IV diagnostic criteria for Asperger’s Disorder (299.80).

A. Qualitative impairment in social interaction, as manifested by at least two of the following:

(1) marked impairments in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction.

(2) failure to develop peer relationships appropriate to developmental level.

(3) a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (eg by a lack of showing, bringing, or pointing out objects of interest to other people).

(4) lack of social or emotional reciprocity.

B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:

(1) encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus.

(2) apparently inflexible adherence to specific, non-functional routines or rituals.

(3) stereotyped and repetitive motor mannerisms (eg hand or finger flapping or twisting, or complex whole-body movements).

(4) persistent preoccupation with parts of objects.

C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning

D. There is no clinically significant general delay in language (eg single words used by age 2 years, communicative phrases used by age 3 years).

E. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interaction), and curiosity about the environment in childhood.

F. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia.

The term in the twenty-first century became controversial after revelations of some of Dr Asperger's activities during the Third Reich (Austria annexed by Germany in 1938) which included his clinic in Vienna sending selected children to be victims of Aktion T4 (a mass-murder programme of involuntary euthanasia targeting those with disabilities), an operation which ran at times in parallel with the programmes designed to exterminate the Jews, Gypsies, homosexuals and others.  While there is no surviving documentary evidence directly linking Dr Asperger to the selection process which decided which children were to be killed, researchers have concluded the records suggest his construction of what came later to be called “Asperger’s syndrome” was actually that very process with an academic gloss.  Because those Dr Asperger so categorized were the autistic children without learning difficulties, they were thus deemed capable of being “cured” and thus spared from the T4’s lists, unlike the “uneducable” who would never be able to be made into useful German citizens.  While the surviving material makes clear Dr Asperger was at least a “fellow traveller” with the Nazi regime, in professional, artistic and academic circles there was nothing unusual or even necessarily sinister about that because in a totalitarian state, people have few other choices if they wish to avoid unpleasantness.  However, it does appear Dr Asperger may have been unusually co-operative with the regime and his pre-1945 publication record suggests sympathy with at least some aspects of the Nazis’ racial theories and eugenics.

Psychache

Psychache (pronounced sahyk-eyk)

Psychological pain, especially when it becomes unbearable, producing suicidal thoughts.

1993: The construct was psyche- + ache.  Psychache was coined by US clinical psychologist Dr Edwin Shneidman (1918-2009) and first appeared in his book Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior (1993).  The prefix psych- was an alternative form of psycho-.  Psycho was from the Ancient Greek ψῡχο- (psūkho-), a combining form of ψυχή (psukhḗ) (soul).  Wit was used with words relating to the soul, the mind, or to psychology.  Ache was from the Middle English verb aken & noun ache (noun), from the Old English verb acan (from the Proto-West Germanic akan, from the Proto-Germanic akaną (to ache)) and the noun æċe (from the Proto-West Germanic aki, from the Proto-Germanic akiz), both from the primitive Indo-European heg- (sin, crime).  It was cognate with the Saterland Frisian eeke & ääke (to ache, fester), the Low German aken, achen & äken (to hurt, ache), the German Low German Eek (inflammation), the North Frisian akelig & æklig (terrible, miserable, sharp, intense), the West Frisian aaklik (nasty, horrible, dismal, dreary) and the Dutch akelig (nasty, horrible).  Historically the verb was spelled ake, and the noun ache but the spellings became aligned after Dr Johnson (Samuel Johnson (1709-1784)) published A Dictionary of the English Language (1755), the lexicographer mistakenly assuming it was from the Ancient Greek ἄχος (ákhos) (pain) due to the similarity in form and meaning of the two words.  As a noun, ache meant “a continuous, dull pain (as opposed to a sharp, sudden, or episodic pain) while the verb was used to mean (1) to have or suffer a continuous, dull pain, (2) to feel great sympathy or pity and (3) to yearn or long for someone or something.  Pyscheache is a noun

Psychache is a theoretical construct used by clinical suicidologists and differs from psychomachia (conflict of the soul).  Psychomachia was from the Late Latin psӯchomachia, the title of a poem of a thousand-odd lines (circa 400) by Roman Christian poet Prudentius (Aurelius Prudentius Clemens; 348-circa 412), the construct being the Ancient Greek Greek psukhē (spirit) + makhē (battle).  The fifth century poem Psychomachia (translated usually as “Battle of Spirits” or “Soul War”) explored a theme familiar in Christianity: the eternal battle between virtue & vice (onto which can be mapped “right & wrong”, “good & evil” etc) and culminated in the forces of Christendom vanquishing pagan idolatry to the cheers of a thousand Christian martyrs.  An elegant telling of an allegory familiar in early Christian literature and art, Prudentius made clear the battle was one which happened in the soul of all people and thus one which all needed to wage, the outcome determined by whether the good or evil in them proved stronger.  The poem’s characters include Faith, Hope, Industry, Sobriety, Chastity, Humility & Patience among the good and Pride, Wrath, Paganism, Avarice, Discord, Lust & Indulgence in the ranks of the evil but scholars of literature caution that although the personifications all are women, in Latin, words for abstract concepts use the feminine grammatical gender and there’s nothing to suggest the poet intended us to read this as a tale of bolshie women slugging it out.  Of interest too is the appearance of the number seven, so familiar in the literature and art of Antiquity and the Medieval period as well as the Biblical texts but although Prudentius has seven virtues defeat seven vices, the characters don’t exactly align with either the canonical seven deadly sins, nor the three theological and four cardinal virtues.  In modern use, the linguistic similarity between psychache and psychomachia has made the latter attractive to those seduced by the (not always Germanic) tradition of the “romance of suicide”.

A pioneer in the field of suicidology, Dr Shneidman’s publication record was indicative of his specialization.

Dr Edwin Shneidman (1918-2009) was a clinical psychologist who practiced as a thanatologist (a practitioner in the field of thanatology (the scientific study of death and the practices associated with it, including the study of the needs of the terminally ill and their families); the construct of thanatology being thanato- (from the Ancient Greek θάνατος (thánatos) (death)) +‎ -logy.  The suffix -ology was formed from -o- (as an interconsonantal vowel) +‎ -logy.  The origin in English of the -logy suffix lies with loanwords from the Ancient Greek, usually via Latin and French, where the suffix (-λογία) is an integral part of the word loaned (eg astrology from astrologia) since the sixteenth century.  French picked up -logie from the Latin -logia, from the Ancient Greek -λογία (-logía).  Within Greek, the suffix is an -ία (-ía) abstract from λόγος (lógos) (account, explanation, narrative), and that a verbal noun from λέγω (légō) (I say, speak, converse, tell a story).  In English the suffix became extraordinarily productive, used notably to form names of sciences or disciplines of study, analogous to the names traditionally borrowed from the Latin (eg astrology from astrologia; geology from geologia) and by the late eighteenth century, the practice (despite the disapproval of the pedants) extended to terms with no connection to Greek or Latin such as those building on French or German bases (eg insectology (1766) after the French insectologie; terminology (1801) after the German Terminologie).  Within a few decades of the intrusion of modern languages, combinations emerged using English terms (eg undergroundology (1820); hatology (1837)).  In this evolution, the development may be though similar to the latter-day proliferation of “-isms” (fascism; feminism etc).

Death and the College Student: A Collection of Brief Essays on Death and Suicide by Harvard Youth (1973) by Dr Edwin Shneidman.  Dr Shneidman wrote many papers about the prevalence of suicide among college-age males, a cross-cultural phenomenon.

Dr Shneidman was one of the seminal figures in the discipline of suicidology, in 1968 founding the AAS (American Association of Suicidology) and the principal US journal for suicide studies: Suicide and Life-Threatening Behavior.  The abbreviation AAS is in this context used mostly within the discipline because (1) it is a specialized field and (2) there are literally dozens of uses of “AAS”.  In Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior (1993) he defined psychache as “intense psychological pain—encompassing hurt, anguish, and mental torment”, identifying it as the primary motivation behind suicide, his theory being that when psychological pain becomes unbearable, individuals may perceive suicide as their only escape from torment.

Although since Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior appeared in 1993 there have been four editions of American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), “psychache” has never appeared in the DSM.  That may seem an anomaly given much in the DSM revolves around psychological disturbances but the reason is technical.  What the DSM does is list and codify diagnosable mental disorders (depression, schizophrenia, bipolar disorder etc), classifying symptoms and behaviors into standardized categories for diagnosis and treatment planning.  By contrast, psychache is not a clinical diagnosis; it is a theoretical construct in suicidology which is used to explain the subjective experience of psychological pain that can lead to patients taking their own lives.  It thus describes an emotional state rather than a psychiatric disorder.

Lindsay Lohan and her lawyer in court, Los Angeles, December, 2011.

Despite that, mental health clinicians do actively use the principles of psychache, notably in suicide risk assessment and prevention and models have been developed including a number of “psychache scales”, self-reporting tools used to generate a metric measuring the intensity of psychological pain (categorized with headings such as shame, guilt, despair et al).  The approaches do in detail differ but most follow Dr Shneidman’s terminology in that the critical threshold is the point at which the patient’s pain becomes unbearable or inescapable and the objective is either to increase tolerance for distress or reframe troublesome thoughts.  Ultimately, the purpose of tools is to improve suicide risk assessments and reduce suicide rates.

DSM-5 (2013).

Interestingly, Suicidal Behavior Disorder (SBD) was introduced in Section III of the DSM-5 (2013) under “Conditions for Further Study”.  Then, SBD chiefly was characterized by a self-initiated sequence of behaviors believed at the time of initiation to cause one’s own death and occurring in the last 24 months.  That of course sounds exact but the diagnostic criteria in the DSM are written like that and the purpose of inclusion in the fifth edition was to create a framework so systematically, empirical studies related to SBD could be reviewed so primary research themes and promising directions for future research could be identified.  Duly, over the following decade that framework was explored but the conclusion was reached there seemed to be little utility in the clinical utility of SBD as a device for predicting future suicide and that more research was needed to understand measurement of the diagnosis and its distinctiveness from related disorders and other self-harming behaviors.  The phase “more research is required” must be one of the most frequently heard among researchers.

In the usually manner in which the APA allowed the DSM to evolve, what the DSM-5s tentative inclusion of SBD did was attempt to capture suicidality as a diagnosis rather than a clinical feature requiring attention.  SBD was characterized by a suicide attempt within the last 24 months (Criterion A) and that was defined as “a self-initiated sequence of behaviors by an individual who, at the time of initiation, expected that the set of actions would lead to his or her own death”.  That sounds uncontroversial but what was significant was the act could meet the criteria for non-suicidal self-injury (ie self-injury with the intention to relieve negative feelings or cognitive state in order to achieve a positive mood state (Criterion B) and cannot be applied to suicidal ideation or preparatory acts (Criterion C).  Were the attempt to have occurred during a state of delirium or confusion or solely for political or religious objectives, then SBD is ruled out (Criteria D & E).  SBD (current) is given when the suicide attempt occurred within the last 12 months, and SBD (in early remission), when it has been 12-24 months since the last attempt.  It must be remembered that while a patient’s behavior(s) may overlap across a number of the DSM’s diagnosises, the AMA’s committees have, for didactic purposes, always preferred to “silo” the categories.

DSM-5-TR (2022).

When in 2022 the “text revision” of the DSM-5 (DSM-5-TR) was released, SBD was removed as a condition for further study in Section III and moved to “Other Conditions That May Be a Focus of Clinical Attention” in Section II. The conditions listed in this section are intended to draw to attention of clinicians to the presence and breadth of additional issues routinely encountered in clinical practice and provide a procedure for their systematic documentation.  According to the APA’s editorial committee, the rationale for the exclusion of SBD from the DSM-5-TR was based on concerns the proposed disorder did not meet the criteria for a mental disorder but instead constituted a behavior with diverse causes and while that distinction may escape most of us, within the internal logic of the history of the DSM, that’s wholly consistent.  At this time, despite many lobbying for the adoption of a diagnostic entity for suicidal behavior, the APA’s committees seem still more inclined to conceptualize suicidality as a symptom rather than a disorder and despite discussion in the field of suicidology about whether suicide and related concepts like psychache should be treated as stand-alone mental health issues, that’s a leap which will have to wait, at least until a DSM-6 is published.

How to and how not to: Informatie over Zorgvuldige Levensbeëindiging (Information about the Careful Ending of Life, 2008) by Stichting Wetenschappelijk Onderzoek naar Zorgvuldige Zelfdoding (The Foundation for Scientific Research into Careful Suicide) (left) and How Not to Kill Yourself: A Phenomenology of Suicide (2023) by Clancy Martin (right).

Informatie over Zorgvuldige Levensbeëindiging (Information about the Careful Ending of Life, 2008) was published by a group of Dutch physicians & and researchers; it contained detailed advice on methods of suicide available to the general public, the Foundation for Scientific Research into Careful Suicide arging “a requirement exists within society for responsible information about an independent and dignified ending of life.”  It could be ordered only from the foundation’s website and had the advantage that whatever might be one’s opinion on the matter, it was at least written by physicians and scientists and thus more reliable than some of the “suicide guides” which are sometimes found on-line.  At the time research by the foundation had found that despite legislation in the Netherlands which permit doctors (acting within specific legal limits) to assist patient commit suicide, there were apparently several thousand cases each year of what it termed “autoeuthanasia” in which no medical staff directly were involved.  Most of these cases involved elderly or chronically ill patients who refused food and fluids and it was estimated these deaths happened at about twice the rate of those carried out under the euthanasia laws.  Since then the Dutch laws have been extended to included those who have no serious physical disease or are suffering great pain; there are people who simply no longer wish to live, something like the tragic figure in Blue Öyster Cult’s (Don't Fear) The Reaper (1976) © Donald Roeser (b 1947):

Came the last night of sadness
And it was clear she couldn't go on
Then the door was open and the wind appeared
The candles blew then disappeared
The curtains flew then he appeared
Saying don't be afraid

There is a diverse literature on various aspects of suicide (tips and techniques, theological & philosophical interpretations, cross-cultural attitudes, history of its treatment in church & secular law etc) and some are quite personal, written variously by those who later would kill themselves or those who contemplated or attempted to take their own lives.  In How Not to Kill Yourself: A Phenomenology of Suicide (2023) by Canadian philosopher Clancy Martin (b 1967), it was revealed the most recent of his ten suicide attempts was “…in his basement with a dog leash, the consequences of which he concealed from his wife, family, co-workers, and students, slipping back into his daily life with a hoarse voice, a raw neck and series of vague explanations.”

BKA (the Bundeskriminalamt, the Federal Criminal Police Office of the FRG (Federal Republic of Germany (the old West Germany)) mug shots of the Red Army Faction's Ulrike Meinhof (left) and Gudrun Ensslin (right).

The song (Don't Fear) The Reaper also made mention of William Shakespeare's (1564–1616) Romeo and Juliet (1597) and in taking her own life (using her dead lover’s dagger) because she doesn’t want to go on living without him, Juliette joined the pantheon of figures who have made the tragedy of suicide seem, to some, romantic.  Politically too, suicide can grant the sort of status dying of old age doesn’t confer, the deaths of left-wing terrorists Ulrike Meinhof (1934–1976) and Gudrun Ensslin (1940–1977) of the West German Red Army Faction (the RAF and better known as the “Baader-Meinhof gang”) both recorded as “suicide in custody” although the circumstances were murky.  In an indication of the way moral relativities aligned during the high Cold War, the French intellectuals Jean-Paul Sartre (1905–1980) and Simone de Beauvoir (1908–1986) compared their deaths to the worst crimes of the Nazis but sympathy for violence committed for an “approved” cause was not the exclusive preserve of the left.  In July, 1964, in his speech accepting the Republican nomination for that year’s US presidential election, proto-MAGA Barry Goldwater (1909–1998) concluded by saying: “I would remind you that extremism in the defense of liberty is no vice!  And let me remind you also that moderation in the pursuit of justice is no virtue!”  The audience response to that was rapturous although a few months later the country mostly didn’t share the enthusiasm, Lyndon Johnson (LBJ, 1908–1973; US president 1963-1969) winning the presidency in one of the greatest landslides in US electoral history.  Given the choice between crooked old Lyndon and crazy old Barry, Americans preferred the crook.

Nor was it just politicians and intellectuals who could resist the appeal of politics being taken to its logical “other means” conclusion, the Canadian singer-songwriter Leonard Cohen (1934-2016) during the last years of the Cold War writing First We Take Manhattan (1986), the lyrics of which were open to interpretation but clarified in 1988 by the author who explained: “I think it means exactly what it says.  It is a terrorist song.  I think it's a response to terrorism.  There's something about terrorism that I've always admired.  The fact that there are no alibis or no compromises.  That position is always very attractive.”   Even in 1988 it was a controversial comment because by then not many outside of undergraduate anarchist societies were still romanticizing terrorists but in fairness to the singer the coda isn’t as often published: “I don't like it when it's manifested on the physical plane – I don't really enjoy the terrorist activities – but Psychic Terrorism.”

First We Take Manhattan (1986) by Leonard Cohen

They sentenced me to twenty years of boredom

For tryin' to change the system from within

I'm coming now, I'm coming to reward them

First we take Manhattan, then we take Berlin

 

I'm guided by a signal in the heavens

I'm guided by this birthmark on my skin

I'm guided by the beauty of our weapons

First we take Manhattan, then we take Berlin

 

I'd really like to live beside you, baby

I love your body and your spirit and your clothes

But you see that line there moving through the station?

I told you, I told you, told you, I was one of those

 

Ah you loved me as a loser, but now you're worried that I just might win

You know the way to stop me, but you don't have the discipline

How many nights I prayed for this, to let my work begin

First we take Manhattan, then we take Berlin

 

I don't like your fashion business, mister

And I don't like these drugs that keep you thin

I don't like what happened to my sister

First we take Manhattan, then we take Berlin

 

I'd really like to live beside you, baby

I love your body and your spirit and your clothes

But you see that line there moving through the station?

I told you, I told you, told you, I was one of those

First We Take Manhattan performed by Jennifer Warnes (b 1947), from the Album Famous Blue Raincoat (1986). 

Whatever they achieved in life, it was their suicides which lent a lingering allure to German-American ecofeminist activist Petra Kelly (1947–1992) & the doomed poet American poet Sylvia Plath (1932-1963) and the lure goes back for millennia, the Roman Poet Ovid (Publius Ovidius Naso; 43 BC–17 AD) in his Metamorphoses telling an ancient Babylonian tale in which Pyramus, in dark despair, killed herself after finding her young love lifeless.  Over the centuries it’s been a recurrent trope but the most novel take was the symbolic, mystical death in Richard Wagner's (1813–1883) Tristan und Isolde (1865).  Mortally wounded in a duel before the final act, Tristan longs to see Isolde one last time but just as she arrives at his side, he dies in her arms.  Overwhelmed by love and grief, Isolde sings the famous Liebestod (Love-Death) and dies, the transcendent aria interpreted as the swansong which carries her to join Tristan in mystical union in the afterlife.  This, lawyers would call a “constructive suicide”.

Austrian soprano Helga Dernesch (b 1939) in 1972 performing the Liebestod aria from Wagner’s Tristan und Isolde with the Berlin Philharmonic under Herbert von Karajan (1908–1989).

While she didn’t possess the sheer power of the greatest of the Scandinavian sopranos who in the mid-twentieth century defined the role, Dernesch brought passion and intensity to her roles and while, on that night in 1972, the lushness of what Karajan summoned from the strings was perhaps a little much, her Liebestod was spine-tingling and by then, Karajan had been forgiven for everything.  Intriguingly, although Tristan und Isolde is regarded as one of the great monuments to love, in 1854 Wagner had written to the Hungarian composer Franz Liszt (1811–1886) telling him:

“As I have never in life felt the real bliss of love, I must erect a monument to the most beautiful of all my dreams, in which, from beginning to end, that love shall be thoroughly satiated.  I have in my head ‘Tristan and Isolde’, the simplest but most full-blooded musical concepion; with the ‘black flag’ which floats at the end of it I shall cover myself to die.”

It’s not known whether Listz reflected on this apparent compositional self-medication for psychache after in 1870 learning from his morning newspaper his daughter Cosima (1837-1930) was to be married to Wagner (then 24 years her senior) but because she’d been for some seven years conducting an adulterous affair with the German the news may not have been unexpected.  He was aware Cosmia’s daughter (Isolde Beidler (1865–1919)) had been fathered not by her then husband (the German conductor Hans von Bülow (1830–1894)) but by Wagner and her second marriage proved happier than the first so there was that.