Neuropsychiatric disorder

“ To sum up: in round figures a quarter of our insane patients show more or less clearly extensive changes and destruction of the brain, while three-fourths have a brain which seems to be generally unimpaired or at most exhibit such changes as give no explanation of the psychological disturbance.
These figures offer the best possible proof that the purely morphological view-point of modern psychiatry leads only very indirectly, if at all, to the understanding of the mental disorder, which is our aim. ”

“ If there be disease of the brain-cortex produced directly by syphilis, of course such disease must give rise to mental disorders; and if the lesion be so situated as to affect the psychic and avoid the motor regions of the brain, it will produce mental disorder without paralysis—i.e. an insanity; again, if such brain disease be widespread, involving the whole cortex, it will cause a progressive mental disorder, accompanied by gradual loss of power in all parts of the body, and ending in dementia with general paralysis ”

“ In isolated cases one may observe convulsive twitchings of the voluntary and involuntary musculature. Finally severe motor excitements set in. The patient becomes noisy, screams, runs aimlessly about, destroys and ruins everything that comes his way. With this the disease has reached its height. At this stage consciousness is entirely in abeyance and the disorder is followed by complete amnesia.” Reich supposes that this acute prison psychosis may be included in that large group of abnormal psychic processes, developing from affect and affect-like situations. ”

“ Statistically this extensive group contains by far the largest number of cases of psychosis. Many psychiatrists would prefer to limit it, and accordingly make use of other nomenclature and classification. From the psychological standpoint the change of name is unimportant, for it is of less value to know what a thing is called than to know what it is. The cases of mental disorder sketched in this essay belong to well-known and frequently occurring types, familiar to the alienist. The facts will not be altered if these disorders are called by some other name than dementia praecox. ”

“ A psychosis which is definitely brought on by a certain environment and which is corrected as soon as the environment is changed, must be looked upon as the product of that environment. That the degenerative soil which permits of the development of these disorders cannot be looked upon as a basic disorder, something like dementia præcox, is likewise unquestionable. These individuals have always shown the same traits of character ”

“ It is true a large proportion of them do have organic disorders in connection with their neuroses. We find that most of them do have functional disorders originating purely in their mind, or because of some constitutional nervous defect and that the real fundamental condition from which they are suffering is not an organic condition but is nervous or mental and must be approached along lines of psycho-therapy. ”

“ There is no case in the world that is more unfairly treated than the neuro-psychiatric case. We all know that by many experiences and observations. So let us give particular and special attention to this subject. ”

“ There Can Be No Neurosis Without a Psychosis.—If the brain is the organ of the mind, then what affects the brain must perforce be at least registered by mind. So every physical shock, accident, toxic condition, infection—even the ordinary cold—rouses the mind at least to awareness, usually to discomfort. For the nerve-cells and fibers—those inseparable parts of the body mechanism—speedily report the fact that they are being tampered with. ”

“ Every mental disturbance corresponds to a disorder in the brain's functions. But there cannot be a change in the functions of the brain without a change in its structure. Thus we must claim that all those so-called functional disturbances like neurasthenia and hysteria, fixed ideas and obsessions, phobias and dissociations of the personality, as well as the typical insane states of the maniac or paranoiac have their basis in a pathological change of the anatomical structure of the brain. ”

“ 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. ”

“ The same form of disease, too, is frequently not transmitted from parent to child or grandchild, but the neuroses, the psychoneuroses, and the cerebro-psychoses, the degenerative forms and the developed forms, are interchangeable. In the ancestry of insanity we find not only actual cerebro-mental disease, but epilepsy, brain disease due to syphilis, habitual drunkenness, any of the severe neuroses, apoplexy, pulmonary consumption, a closely-allied disease, and suicide. ”

“ Those who handled best the neuropsychiatric problems of the present war were in large part qualified not merely by a knowledge of psychology and psychiatry, but far more by a thorough training in organic neurology. The problems of psychiatry can be grasped fully only by those who have a fundamental knowledge of the anatomy, physiology, and diseases of the nervous system.
Dr. Southard, preëminently a neuropathologist, is well grounded in organic neurology, and shows at every turn his capabilities for considering the neuroses, psychoses, and insanities from the standpoint of the neurologist. ”

“ Periodical recurrence of the act under identical circumstances, and an impulsive manner in carrying it out, give rise to weighty presumptions that it is of pathological significance. The decision, however, must follow after referring the act to its psychological motive (abnormalities of thought and feeling) , and after showing this elementary anomaly to be but one symptom of a general neuropathic condition,—either an arrest of mental development, or a condition of psychical degeneration, or a psychosis. ”

“ The studies of Meyer, Hoch, Kraepelin, Freud, Jung, Bleuler and many others have shown that in manic-depressive insanity, dementia praecox and various other psychoses we are dealing with very definite constitutional conditions, morbid temperaments, personality defects, etc., which are responsible for the maladjustments leading to the development of psychoses. Financial reverses, domestic difficulties, the death of near relatives, the ordinary hardships and disappointments of life, even ill health, do not as a rule mean the development of a psychosis in the normal, properly balanced individual. ”

“ Looking backward to our Civil War, one is strongly impressed with the fact that the present volume, one of the earliest works of its kind to appear in book form, deals largely with psychiatry and functional nervous diseases, whereas during and after the American conflict the most important contributions to neurology related to organic disease, especially as illustrated by the work of Weir Mitchell and his collaborators on injuries of nerves. ”

“ While it may be said that every psychosis is accompanied by a correlated neurosis, it cannot be maintained that every neural change is attended with consciousness. The nutritive processes in the tissues of the brain during sleep have no mental concomitants. ”

“ It is an established fact that drugs do not affect brain structure; and it is equally well known that, in most instances, insanity causes no deterioration in nerve tissue. In these facts lies strong collateral proof that the sources of mental disease are to be sought elsewhere than in the brain. Injuries and ailments that involve change in brain substance will necessarily interfere with brain function, and, in softening of nerve tissue or in any inflammation, there are organic alterations that may be seen and noted. ”

“ These are a few examples of the perturbations of conduct common to neurotic sufferers and the diseased in mind. One perceives that the same laws relating to the diminution of force and the lowering of the psychological tension intervene in the same way with the one as with the others. The distinctions, which have been established for social reasons and practical conveniences, no longer exist when one tries to find, by analysis of the symptoms, the nature of neuroses and psychoses. ”

“ The term neurosis is now generally used synonymously with psychoneurosis, although it has been applied to certain disorders in which, while the symptoms are both mental and physical, the primary cause is thought to be essentially physical. In most instances, however, both psychogenic and physical causes are operative and we can assign only a relative weight to the one or the other. ”

“ 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. ”

“ The two major divisions of mental disease—psychosis and psychoneurosis—are not always readily differentiated. In the psychotic, the personality is usually distorted, whereas in the psychoneurotic the personality remains normal in relation to the realities of the world and social life. The psychotic is the more [Pg 63] obviously deranged, the psychoneurotic usually passes for almost normal. ”

“ Again, an answer will, no doubt, be demanded by some people to the question—How does that which, objectively considered, is neurosis become subjectively felt as psychosis? Is not the identification of neurosis and psychosis a begging of the question, unless the how, the modus operandi, is explained? ”

“ The varying degrees in which the various portions of the cortex, medullary portion, and different ganglia of the brain may be involved in the morbid process naturally give rise to a great variety in the symptoms, mental and physical, sensory and motor, emotional and intellectual, and in the relative preponderance of one or another in individual cases. The usual symptoms of any form of mental disease may for a time obscure the dementia which sooner or later must appear in general paralysis, and which, as has already been said, is the only mental symptom universally present in all cases. ”

“ Every one admits that organic alterations more or less momentary, but actually not suspected, must exist in neuroses as in other diseases. Neuroses as well as psychoses are much more likely to be diseases with unknown lesions than diseases without lesions, and it is impossible to take this characteristic into account to distinguish the ones from the others. ”

“ This dogma leads to absolute sterility as soon as universal validity is ascribed to it. There are undoubted psychogenic mental diseases (the so-called hysterical) which are properly regarded as functional in contrast with organic diseases which rest upon demonstrable anatomical changes. Disorders of the brain should only be called organic when the psychic symptoms depend upon an undoubtedly primary disease of the brain. Now in dementia praecox this is by no means a settled question. ”

“ The mental symptoms may be entirely overlooked in the first stage. There is a gradual progressive deterioration of the personality, with a loss of efficiency, impairment of memory, and failure of judgment. There may be episodes of excitement, depression or delirium, with or without hallucinations and delusions, the latter being either hypochondriacal or grandiose. "The demented type, without marked delusions or sensory falsifications, is the truly typical variety of the disease and the dementia the basal element of all forms" (White) . ”

“ Neither one can be accomplished by means of a medically effective treatment that is applied to the patient until a cure occurs.
A few emotional problems fall under the heading of true psychiatric disorders and result from physical causes. They include, for example, epilepsy, drug addiction, and Alzheimer's disease. But these conditions are in the minority; most emotional "disorders" have not been traced to underlying organic causes. There are several currently competing hypotheses relating to possible biochemical bases of schizophrenia, mania, depression, and anxiety disorders. ”

“ The differentiation of these conditions as suggested in the statistical manual of the American Psychiatric Association is as follows:—
"The diagnosis should be restricted to mental disorders arising as a direct or obvious consequence of a brain (or head) injury producing psychotic symptoms of a fairly characteristic kind. The amount of damage to the brain may vary from an extensive destruction of tissue to simple concussion or physical shock with or without fracture of the skull. ”

“ If one wished to establish a scientific distinction between neuroses and psychoses, I should say, in a summary fashion, that in neuroses the reflection alone is disturbed, that in psychoses the immediate assent itself is affected. The shrinkage of the conscience, doubts, aboulias, obsessions, scruples are always disorders of the reflected will and belief. ”