Dementia praecox

“ A more decided step in the development of the dementia praecox concept was the description by Kahlbaum of katatonia in 1874. This may be ushered in by an early stage strongly suggesting hebephrenia but terminating usually in a depression followed by states of excitement, stupor and dementia. The characteristic [442] features of the disease are the peculiar catatonic stupor so-called, and forms of excitement differing materially from those exhibited in the manic-depressive psychoses. Hallucinations and delusions are almost invariably present. ”

“ It is possible to make certain a priori speculations as to prognostic criteria based on classification and what that implies. We know that pure paranoia is not a deteriorating psychosis—that it does not necessarily preclude the possibility of considerable social usefulness—and that it grades off almost imperceptibly into dementia praecox. The features differentiating these two diseases should therefore supply us with data for determining the prognosis. A case undoubtedly, praecox, which shows markedly the differential features of paranoia, should have a proportionately better outlook. ”

“ It must be noted that not infrequently cases of dementia præcox give test records that cannot be distinguished from normal. It seems that the pathological associational tendencies constitute merely a special group of symptoms, some of which may be expected to be manifest in cases which have reached a state of advanced mental deterioration, but may not necessarily be present in the early stages of the disease. ”

“ However far we are from being able to understand fully the concatenations of that obscure world, at least we may maintain, with complete assurance, that in dementia praecox there is no symptom which can be described as psychologically baseless and meaningless. The most absurd things are in reality symbols of ideas which are not only generally understandable, but also universally operative in the human heart. In insanity we do not discover anything new and unknown, but we look at the foundation of our own being, the source of those life-problems in which we are all engaged. ”

“ In them the psychosis develops and takes its definitely determined course independently of the milieu in which the individual happens to be placed. In the majority of instances they suffer from the various forms of dementia præcox and progress toward demential end-results in the same proportion as the general run of dementia præcox cases do, whether or not they have come in conflict with the law. Occasionally we also see a case of organic brain disease or manic-depressive psychosis, and in more frequent instances a case of epilepsy. ”

“ Therefore, this period of life is also that in which the first clearly developed neuroses arise. The tendency of this age is one directly opposed to that of dementia præcox. The child seeks to win the world and to leave the mother (this is a necessary result) . The dementia præcox patient, however, seeks to leave the world and to regain the subjectivity of childhood. We have seen that in dementia præcox the recent adaptation to reality is replaced by an archaic mode of adaptation; that is to say, the recent idea of the world is rejected in favor of an archaic idea of the world. ”

“ A similar narrow-mindedness, but of the highest intensity, we frequently observe in dementia præcox, especially in the paranoid form. It is hardly necessary to give examples. Orientation in both diseases changes in a similar capricious manner. In dementia præcox, where one is not actually dealing with marked excitability and deep confusion, we often get the impression that the patients are only disturbed by illusions, but that in reality they are properly oriented. ”

“ That neither apprehension nor retention take part as a rule in the general deterioration, seems at first sight rather singular. As a matter of fact one can find in dementia præcox during accessible moments that there exists a surprisingly good, and an almost photographic memory, which preferably takes note of the most indifferent things that unfailingly escape the notice of normal persons. ”

“ If we agree with Kraepelin and others that dementia præcox has a more or less definite onset, a more or less definite course and termination in a dissolution of the individual’s psyche, our case is not one of dementia præcox. Our patient has had the same attributes of character and personality always. ”

“ The psychological mechanisms of dreams and hysteria are most closely related to those of dementia preæcox. A comparison with dreams is therefore not too daring. In dreams we see how reality is spun with fanciful creations, how the pale memory pictures of the waking state assume tangible forms, and how the impressions of the environment adapt themselves to the sense of the dream. The dreamer finds himself in a new and different world which he has projected out of himself. Let the dreamer walk about and act like one awakened and we have the clinical picture of dementia præcox. ”

“ In dementia præcox we have a re-direction of attention and interest to primitive fantastic thoughts and a consequent perversion of energy and emotion. In many malignant stupors one can detect evidence of this second type of reaction in symptoms that are anomalous for stupor. ”

“ It is, therefore, no wonder that such theories, the forming of and adherence to which are favoured even by parents and educationalists should later become determinants for important symptoms in a neurosis, or of delusions in a psychosis, just as I have shown that in dementia præcox [144] what has existed in the mind for years always remains somewhere, though it may be hidden under compensations of a seemingly different kind. ”

“ Knowing how the incongruity is brought about in hysteria, is it still necessary that we should accept a totally new mechanism in dementia præcox? In general we know by far too little about the psychology of the normal and hysteric [59] to dare to accept in such an untransparent disease as dementia præcox, a totally new mechanism unknown to all psychology. One should be economical with new principles of interpretation. It is for this reason that I repudiate the clear and ingenious hypothesis of Stransky. ”

“ On the other hand the slightest remark touching the complex even remotely, immediately excites violent anger and painful outbreaks which may assume disproportionate dimensions. (In a case of dementia præcox we may note that when asked whether he is married, the patient falls into inadequate laughter or he begins to cry and becomes completely negativistic, or he shows an obstruction, etc.) Had we not the means to look into the mind of a normal lover we would have to consider his behavior that of a hysteric or catatonic. ”

“ Rejected for the Year 1911
psychoses exactly equals that of the Jews admitted for dementia prsecox. Now, dementia præcox is classed as one of the insanities depending upon a constitutionally inferior mental make-up, as is likewise manic-depressive insanity. These two constitutional inferior groups which are universally agreed to rest upon a bad heredity, alone account for over 55 per cent, of the insanities among the Jews in the above table. Statistics could be multiplied almost indefinitely to show similar results. ”

“ The peculiar symptoms of dementia praecox as a rule are a result of the individual's inability to make compensatory readjustments. In the paranoid forms the patient entirely reconstructs his psychical life. White [304] attempts to explain the meaning of some of these delusional formations in his "Outlines of Psychiatry":—"The relation of the delusion to the complex is often obvious if one is familiar with the more important of the infantile material. A man believes himself [449] pregnant, that a child is in his stomach. ”

“ Dementia præcox has here pierced the investment of consciousness, that is, destroyed the function of the clearest purposive associations, so that it is now possible to see from all sides the automatic workings of the unconscious complexes. What the patient and we see are only the complicated, distorted and displaced products of complex-ideations which are analogous to our dreams, wherein we only see the dream-picture but not the complex-thought hidden beneath it. Thus the patient takes her dream productions also as substantial and claims that they are realities. ”

“ Finally, real religious faith has a pragmatic value. Granting it be only a theory it nevertheless produces results in conduct. This is in sharpest contrast to religious delusions. They never lead to sustained effort, they bring with them no social potentiality. They exist for the comfort of the patient alone.
To sum up: We have endeavored to establish the claim that delusions in dementia praecox which takes the form of objective speculations rather than subjective experiences are an evidence of a milder psychotic reaction and hence warrant a prognosis of chronicity rather than deterioration. ”

“ Attention in dementia præcox is, so to say, regularly disturbed, but the same disorder also plays a great part in the realms of hysteria. Janet notes the following as to the "troubles de l'attention": "One can say that the main trouble exists not only in a suppression of the intellectual faculties, but in the difficulty of fixing the attention. ”

“ During a period of six years (1912 to 1918) a study of first admissions to the New York state hospitals shows an incidence of dementia praecox in the native-born of 75.2 per hundred thousand of the population and in the foreign born of 161.4. The importance of this is shown by the fact that over fifty per cent of the entire hospital population is made up of cases of dementia praecox.
The necessity of some supervision of immigration for the purpose of preventing the entrance of undesirable aliens has long been recognized. ”

“ The observations and intimations plucked from the different realms of dementia præcox point above all to the idea of a real central disturbance which is designated by different names, such as apperceptive dementia (Weygandt) , dissociation, abaissement du niveau mental (Janet, Masselon) , disintegration of consciousness (Gross) , disintegration of personality (Neisser et al.) . Then there arose the idea of tendency towards fixation (Masselon, Neisser) and from this Neisser adduces the emotional dementia. Freud and Gross find the important fact of the presence of split-off series of ideas. ”

“ The somewhat frequent remissions in dementia praecox make the task all the more difficult. To be sure, the stuporous and catatonic cases are not very much in evidence in the army; when such cases do occur, it is easy enough to evacuate the patients to a hospital for observation. Far more troublesome are cases of a less advanced or milder nature. Here are cases in which judgment is deficient, and in which quite unsystematic, incoherent, and transient delusional ideas occur. The patient looks quite normal to the non-psychiatric expert. ”

“ Like all victims of dementia præcox, when the disorder conditions bizarre conduct for the first time in mid-maturity, he becomes profoundly egocentric, neglectful of his appearance and of his person, and callously insensitive to the feelings and rights of others. ”

“ If even a normal individual is not always clear about the causes of his ill-humor, how little can we know when confronted with the mind of a precocious dement? On account of the evident inadequacy of our psychological diagnosis, we must be very careful about the supposition of a real incoördination in the sense of Stransky. Although judging from clinical appearances there are frequent incongruities, they are by no means exclusively limited to dementia præcox. In hysteria, likewise, the incongruity is an every-day occurrence. ”

“ By the application of the association test, according to the method here proposed, no sharp distinction can be drawn between mental health and mental disease; a large collection of material shows a gradual and not an abrupt transition from the normal state to pathological states.
In dementia præcox, some paranoic conditions, manic-depressive insanity, general paresis, and epileptic dementia the test reveals some characteristic, though not pathognomonic, associational tendencies. ”

“ We can readily understand why the content of the delusions and hallucinations are of such a nature and of no other; but why non-hysterical delusions and hallucinations should at all appear we do not know. Here at the basis of all there should be one physical cause embracing all the psychological ones. Let us assume with Freud that every paranoid form of dementia præcox runs according to the mechanism of hysteria, but why is the paranoid unusually stable and resistive, while hysteria is characterized by the great mobility of its symptoms? ”

“ To Freud, however, belongs the credit of being the first to show in a case of paranoid dementia præcox the "principle of conversion" (repression and indirect reappearance of the complexes) . Nevertheless the mechanisms of Freud do not reach so far as to explain why there originates a dementia præcox and not a hysteria; hence it must be postulated that for dementia præcox there is a specific resultant manifestation of affects (toxins?) which causes the definite fixation of the complex by injuring the sum total of the psychic functions. ”

“ The explosive excitements in dementia præcox may be brought about in the same way as the explosive affects in hysteria. Every person treating hysteria is acquainted with the sudden affect and acute exacerbations of the symptoms. Frequently we are confronted with a psychological riddle and deem it sufficient to note "patient is again excited." But a careful analysis always discovers a clear reason for the excitement ”

“ Following Freud, fixation of affects means that the repressed complexes (the carriers of affects) can no more be disconnected from the contents of consciousness, they remain and so prevent the further development of personality.
To avoid misconceptions I must here add that the continued persistence of a strong complex in normal psychic life can lead only to hysteria. Yet the consequent manifestations of the hysterogenic affect are different from the symptom-complex of dementia præcox. For the origin of dementia præcox we must demand a totally different disposition than we do for hysteria. ”