August Hoch

“ There is probably not one of the ideas expressed by these patients which cannot be duplicated in myths. We have, therefore, a right to speak of these ideas as "primitive," and to see in them, not only deep-seated strivings of the human soul, but to recognize in them an essential inner relationship. It is especially this last fact to which at this point we wish to call attention: that without any obvious connection the fantasies of our forefathers recur in the delusions of our stupor cases. We presume that in each case they represent a fulfillment of a primitive human demand. ”

“ As a result of our own observations the only thing we feel at liberty to state with real confidence is that catalepsy is presumably a phenomenon mental in origin rather than somatic, because it always occurs in conditions which show other evidence of mentation.
Whatever may be the origin of the idea of the posture assumed, there can be little doubt that its indefinite maintenance is a phenomenon of perseveration. The conception of the position being in the patient's mind, it is easier to hold it than elaborate another idea. This, of course, is part of the intellectual disorder in stupor. ”

“ The patient, then, has an indefinite and stupid expression, he understands questions put to him with difficulty, and answers them with effort or not at all. He seems overwhelmed with sleep, he forgets to withdraw his tongue after showing it to the doctor, he complains of no uncomfortable sensation, of no illness, he seems to take no interest in what goes on about him.... The stupor patient is a fool who does not speak, in this being more tolerable than the one who speaks [delightful naiveté!] ”

“ In the first place, the dissatisfaction with life, the first phase of regression, leads to the quietness—the inactivity and apathy, which are the most fundamental symptoms of the stupor reaction as a whole. Initiative is lost and with this comes a tendency for the acceptance of other people's ideas. That is the probable basis for the suggestiveness which we concluded was a prominent factor in catalepsy. Indifference and stolidity may exist with those milder degrees of regression which do not conflict with one's critical sense, and hence may be present without any false ideas. ”

“ To this end we first examined typical cases of deep stupor and found that the clinical picture is made up of the following symptoms: In the foreground stands poverty of affect. The patients are almost unbelievably apathetic, giving no evidence by speech or action of interest in themselves or their environment, unmoved even by painful stimuli. Their faces are wooden masks; their voices as colorless when words are uttered. In some cases sudden mood reactions break through at rare intervals. The second cardinal symptom is inactivity. ”

“ We have described typical cases of benign stupor and isolated certain interrelated symptoms which, when they dominate the clinical picture, we believe establish the diagnosis of stupor, regardless of the severity of the reaction. These symptoms are apathy, inactivity, a thinking disorder and, quite as important as these, an absorbing interest in death. It is typical that the patient contemplates his dissolution with indifference or, at most, with mild or sporadic anxiety. ”

“ Carried to the extreme, regression leads one in type of thinking and in ideas back to childhood and earliest infancy. The final goal is a state of mental vacuity such as probably characterizes the infant at the time of birth and during the first days of extra-uterine life. In this state what interest there is, is directed entirely to the physical comfort of the individual himself, and contact with the environment is so undeveloped that efforts to obtain from it the primitive wants of warmth and nutrition are confined to vague instinctive cries. ”

“ The most important difference between stupor and depression lies in the affect. Although inactive and sometimes appearing dull the depressive individual is not apathetic but is suffering acutely. He feels himself wicked, paralyzed by hopelessness, and finds proof of his damnation in the apparent change of the world to his eyes and in the slowness of his mind. ”

“ Psychiatrists are more or less aware of there being typical ideational contents in the different manic-depressive psychoses. For instance, every one is familiar with ideas of wickedness and inadequacy in depression, ideas of violence in anxiety, or expansive and erotic fancies in manic states. Quite similarly we have seen that death is a dominant topic in a stupor. Now in addition to these typical ideas we often hear expressed what we might term non-specific delusions, ideas that seem to have nothing to do with a peculiar type of reaction which the patient presents. ”

“ If the stupor reaction be a regression, which is essentially a withdrawal of interest and energy rather than a fixation on a false object, then excitement is desirable and interest must be reawakened. The withdrawal is temporary (inasmuch as the psychosis is benign) , but just as a normal person wakes more readily on a clear sunshiny day than when it rains, so the more cheering the environment the more rapid the recovery. ”

“ INTRODUCTION AND TYPICAL CASES OF DEEP STUPOR
The fact that psychiatry lags in development and recognition behind other branches of medicine is due in part to the crudity of its clinical methods. The evolution of interest in science is from simple, obvious and tangible problems to more intricate and impalpable researches. Refined laboratory work has been done in psychiatric clinics, particularly along histopathological lines, but clinical studies follow antiquated methods. The internist does not say, "The patient has sugar in his urine, therefore he has diabetes and therefore he will die." ”

“ It is important to note that objectively the resemblance between sleep and stupor is striking. So far as mental activity in either state can be discovered by the observer, either the sleeper or the patient in stupor might be dead. Briefly stated, then, our hypothesis of the psychological determination of stupor is that the abnormal individual turns to it as a release from mental anguish, just as the normal human being seeks relief in his bed from physical and mental fatigue. When this desire for refuge takes the shape of a formulated idea, there are delusions of death. ”

“ We are here concerned with a clinical study, and therefore, among other tasks, with the interrelationship of symptoms, but for that purpose it is necessary to point out how these ideas seen in stupor can be shown to have, not only a connection amongst each other, when viewed as deep-seated human strivings, but also are closely related to, or identical with, ideas found in mythology.
To one's conscious mind death may be not only the dreaded enemy who ends life, but also the friend who brings relief from all conflict, strife and effort. ”

“ We are now in a position to define more narrowly what death means in stupor. It is an accepted fact, a Nirvana state. When death means union with God or appears in other religious guise, manic symptoms tend to develop. When it is unwelcome and appears as "being killed," we find anxiety symptoms. A patient can conceive of death variously and have [167] various clinical pictures. A knowledge of the metamorphoses of ideas and their relationship to other symptoms enables us to understand such cases, that, without this key, seem confused and lawless jumbles of symptoms. ”

“ Running through all the stages of stupor, however, there is an emptiness, an indifference that is in striking contrast to the positive pain that is felt or expressed by the depressed patient. It may be objected, of course, that this apathy really represents the final stage in the emotional blocking of the depressed individual, but the development of stupor and recovery from it shows an entirely different type of process. A deep depression recovers by changing the point of view from a feeling of unworthiness and self-blame to one of normality. ”

“ When death is accepted but mental function has not ceased, the latter is confined to a dramatization of death in physical symptoms or to such speech and movements as indicate a belief that the patient is dead, under the water, or in some such unreal situation. Finally, when all evidence of mentation in any form is lacking, we see clinically the condition which we know as deep stupor and which we must regard psychologically as the profoundest regression known to psychopathology, a condition almost as close to physiological unconsciousness as that of the epileptic. ”

“ The innate desire for rest and a fresh start is almost as fundamental a human craving as is the tendency to seek release in death. In fact the two are closely associated both in literature and in daily speech, for in many phases we correlate death with new life. If one is to visualize or incorporate the conception of new life in one term, rebirth is the only one which will do it, just as death is the only [190] word which epitomizes the idea of complete cessation of effort. ”

“ The patient often had an expression of bewilderment. She was also more in contact with her environment than many stuporous patients are, for, not infrequently, she would look at what was going on about her. Her apathy was also broken into in a marked degree by her active resistiveness, which was sometimes accompanied by plain anger. It seems that a prospect of death may occur in other instances in a totally affectless state. We have recently seen it in a partial stupor during which the patient spoke and had this persistent idea in a setting of complete apathy. ”

“ The instinct of self-preservation may prevent the individual from welcoming the notion of dissolution, so that this latter idea, though insistent, is not accepted but reacted to with anxiety; hence we often meet with onsets of stupor characterized by emotional distress. It has already been suggested that death may foreshadow another existence. Often in the psychoses we meet with the idea of eternal union in death with some loved one whom the vicissitudes and restrictions of this life prevent from becoming an earthly partner. This fancy is frequently the basis of elation. ”

“ Progressive thinking is therefore adaptive, while regressive thinking is fantastic in type, as well as concerned with the past—a past which in fancy takes on the luster of the Golden Age. Sanity and insanity are, roughly speaking, states where progressive or regressive thinking rule. The essence of a functional psychosis is a flight from reality to a retreat of easeful unreality. ”

“ In Chapter VIII the differential diagnosis between perplexity and stupor has already been touched upon. Here again the affect is a point of contrast. The patient has not too little emotion but too much. The feeling of intangible, puzzling ideas and of an insecure environment causes the subject distress, of which complaint is made and which can be witnessed in the furrowed brow and constrained expression. There is also, as we have seen, a rich ideational content in these cases, if one can get at it. The mind is not a blank, as in the stupor, or concerned only with delusions of death. ”

“ Without interest there is no attention and no registration. The patient in stupor presents just the memory defect which we would expect. Indifference to his environment leads to a poor memory of external events, while on recovery there may be such a divorce between consciousness of normal and abnormal states that the past delusions are wiped from the record of conscious memory. Withdrawal of energy then produces not only inactivity and apathy but grave defects in intellectual capacity. ”

“ The chronic and deteriorating cases give up the struggle permanently, while the temporary insanities lay bare the soul of man as he catches a glimpse of unreality but turns back to face the world as it is. When one realizes that emotional disturbances are characteristic of the benign psychoses, it is easy to imagine how much such studies [ix] may ultimately illuminate the problems of normal life.
The technical value of this work to psychiatry is more immediate. Kraepelin laid the foundations for systematic classification with his dementia præcox and manic-depressive groups. ”

“ Thoughts concerned with future and new activities require energy for their completion in action and are therefore naturally accompanied by a sense of effort which gives pleasure to an active mind. When the sum of energy is reduced, one observes a reverse tendency called "regression." It is easier to go back over the way we know than to go forward, so the weakened individual tends to direct his attention to earlier actions or situations. To meet a new experience one must think logically and keep his attention on things as they are, rather than imagine things as one would like to have them. ”

“ The attention being given wholly to fantasies, the subject lies motionless, mute and placid, although passing through varied autistic experiences. Only when the dream becomes too vivid, disturbs sleep and re-directs attention to the environment—only then is emotion objectively [203] betrayed. There is an appearance of apathy and mental vacuity which the dreamer can soon declare to be false. He was feeling and thinking intensely. In any condition, therefore, such as that of perplexity or of an absorbed manic state, the patient may be objectively in the same condition as a typical stupor. ”

“ A mere slowing of thought processes accompanied by subjective feeling of effort is the limit reached in true depression, while it is merely the beginning of the intellectual disorder in stupor, for one meets with retardation symptoms only in the partial stupors. The slowing in these cases seems to represent an early stage of the intellectual disturbance which reaches its acme in the mental vacuity and complete incompetence of the deep stupor, just as slow movements in the partial stupors seem to represent a diluted inactivity reaction. ”

“ With complete inactivity there is almost always consistent mutism, and perfect freedom of speech does not, as a rule, appear until the movements are free. In between these extremes all variations are possible, even the deepest stupors are occasionally interrupted by one or two words; for instance, a patient may remain comatose, as it were, and absolutely mute for six months, then to every one's surprise say one or two words and relapse into a year of silence. Again one sees cases where movements have become fairly free and yet the patient says nothing. ”

“ A patient may swing from mania to stupor as from mania to depression, and when the partial stupors are recognized as milder forms of the same process, it seems to be a frequent type of reaction.
If stupor be a reaction type, its laws must be psychological. According to the view of modern psychopathology, the essence of insanity is regression with indolent thinking as opposed to progressive and energetic mentation. One can look on stupor as being a profound regression. ”

“ A vision of a new world is a content occurring not infrequently in manic states, but before the universe can be remolded it must be destroyed. Before the individual can enjoy new life, a new birth, he must die, and stupor often marks this death phase of a dominant rebirth fantasy. In this connection it was not without significance to note that stupors almost universally recover by way of attenuation of the stupor symptoms, or in a hypomanic phase where there seems to be an abnormal supply of energy. Antæus-like, they rise with fresh vigor from the Earth. ”