Stupefaction

“ 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. ”

“ 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. ”

“ He falls into a stupor, into utter oblivion of the world about him, becomes in turn excited and confused, his senses begin to functionate in a fallacious manner, and he thus succeeds in shutting out from consciousness, for the time being at least, the entire unbearable situation. Upon emerging from his stupor he has a more or less complete amnesia for the deed and its attending circumstances, and finding himself confronted with accusations, cross-examinations, and lastly, conviction, he at once sets about, so to speak, to square himself with the situation. ”

“ Affect: Complete affectlessness is an integral part of the stupor reaction. Modification of the statement will later be mentioned. The patient is indifferent so far as his basic condition is concerned, and it is only by certain stimuli that at times emotional reactions can be elicitated, some tears at a visit of a relative, an appropriate smile at a joke or a comical situation when the stupor is not too deep or an angry reaction called forth by interference.
Catalepsy: Waxy flexibility or merely a tendency to maintain artificial positions is a frequent but not an essential symptom. ”

“ Our description of the mood reactions in stupor would be incomplete if we omitted to mention the occasional appearance of an emotional attitude not unlike that seen in many cases of involution melancholia, which reminds one in turn of the reactions of a spoiled child. The commonest of these manifestations is resistiveness that may occur when an examination is attempted, feeding is suggested, or a sanitary routine insisted upon. One also meets with resentfulness. One patient, who frequently showed this reaction, explained it retrospectively by saying that she wanted to be left alone. ”

“ The typical ideational content and many of the symptoms of stupor are to be explained as expressions of death, for a regression to a Nirvana-like state can be most easily formulated in such a delusion. Other clinical conditions may temporarily and superficially resemble stupor on account of the [204] attention being misdirected and applied to unproductive imaginations. To employ our metaphor again, in these false stupors the current is switched to another, invisible machine but not cut off as in true stupor. ”

“ In so far as inactivity is merely an expression of apathy, its causation will be considered in connection with the psychology of the stupor reaction as a whole. In so far as there may be specific factors, however, it may be of interest to consider what information the patients themselves give us from time to time as to what determined their inactivity. It is really surprising how frequently something can be gained either from careful notes taken during the stupor or from the retrospective accounts of the psychotic experiences. ”

“ In any functional psychosis an offhand diagnosis is dangerous. When one deals with such a condition as stupor, however, the problem is exacting, for, although "stupor" may be seen at a glance, what is seen is really only a symptom or a few symptoms. ”

“ This gives us, therefore, five states which may be analyzed for the symptoms of partial stupor. The pictures of all five are unusually consistent. There is inactivity, marked but not complete; poverty of affect without perfect apathy; and a marked interference with the intellectual processes. The last can be studied better than in the deep stupors because these partial cases are more or less accessible to examination. There is a tendency for the patient to think much of death either in the onset or during the psychosis. Negativism seems much less prominent than in the deep stupors. ”

“ In one case we found a marked cyanosis in the extremities. Case 2 showed marked loss of hair. Gain in weight is never observed and marked emaciation is the rule. This we may attribute to the refusal of food.
[33] A perusal of these cases, then, shows that the dominant (and well-nigh exclusive) symptoms of the stupor are inactivity, apathy, negativism and disturbance of the intellectual functions. Benign stupor can be defined as a recoverable psychosis characterized by these four symptoms. The meaning of such vague physical manifestations as the low fever is not clear. ”

“ These formulations of the death idea may occur as tentative solutions of the patient's problems leading to temporary manic episodes while the psychosis is incubating. It seems that stupor as such appears only when death and nullity are accepted.
The above are more or less a priori reasons for regarding the stupor as a regressive reaction. We must now consider the clinical evidence to support this view. In the first place, we always find that stupor occurs in an individual who is unhappy and [192] who has found no other solution than regression for the predicament in which he is. ”

“ We believe that there is just as distinctive a stupor reaction which may be exhibited either in deep stupors or what we may term partial stupors. Theoretically, complete apathy, inactivity, etc., make up the clinical picture of a deep stupor. When these symptoms appear rather as tendencies than as perfect states, a partial stupor is the product. That partial stupors occur as well-defined psychoses, developing and disappearing without the appearance of deep stupor, we shall attempt to show in the following three typical cases ”

“ 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. ”

“ 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 combination of the stupor tendency to apathy with the mood of another reac [245] tion is probably the only combination of affects to be met with in psychiatry.
The stupor reaction, then, is a simple regression, with a limitation of energy, emotion and ideational content, the last being confined to notions of death. All functional psychoses are regressions. How do the others differ from this? We need only answer this question in so far as it concerns the clinical states resembling benign stupors. Stupors occur frequently in catatonic dementia præcox. ”

“ Turning now to the symptoms of the stupor proper, we note, first, the effects of the loss of energy which regression implies. The inactivity and [195] apathy which these patients show is too obviously evidence of this to require further comment. Another proof of the withdrawal of the libido or interest is found in the thinking disorder. Directed, accurate thinking requires effort, as we all know from the experience of our laborious mistakes when fatigued. So in stupor there is an inability to perform simple arithmetical problems, poor orientation is observed, and so on. ”

“ 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. ”

“ In other cases stupor is predominant, and the person sits in silence and in the same attitude. Some resent interference, others are easily persuaded by their attendants to do certain acts, but when done relapse again into stupor. They manifest extreme apathy. ”

“ If benign stupors belong to this group, then we should be able to find some specific psychology for this type of reaction.
All speech and all conduct, except simple reflex behavior, are presumably determined by ideas. When an individual is not aware of the purpose governing his action, we assume, in psychological study, that an unconscious motive is present, so that in either case the first step in psychological understanding of any normal or abnormal condition is to discover, if possible, what the ideas are that lead to the actions [187] or utterances observed. ”

“ Closely related to the apathy, and probably merely an expression of it, is the inactivity which is both muscular and mental. It exists in all gradations from that of flaccidity of voluntary muscles, with relaxation of the sphincters, and from states where there is complete absence of any evidence of mentation to conditions of mere physical and psychic slowness. After recovery the stupor patient frequently speaks of having felt dead, paralyzed or drugged. ”

“ So often a stupor begins with the same indefinite kind of upset as does another psychosis that the development may furnish no clew. Any condition where there is inactivity, scanty verbal productivity and poor intellectual performance resembles stupor. This triad of symptoms occurs in retarded depressions, in absorbed manic states and in perplexities. Negativism and catalepsy are never well developed except in stupor. So if these symptoms be present the diagnosis is simplified. But they are often absent from a typical stupor. ”

“ The French, beginning with Pinel in the 18th Century, were the first to write extensively of stupor. An excellent paper by Dagonet [13] appeared in 1872, in which such literature as had appeared up to that time is discussed. He defines "Stupidity" as a form of insanity in which "delirious" ideas may or may not be present, which has for its characteristic symptoms a state of more or less manifest [250] stupor and a greater or less incapacity to coördinate ideas, to elaborate sensations experienced and accomplish voluntary acts necessary for adaptation. ”

“ His view is that pains tend to preserve the mutism and amnesia, so that there are "inhibitory processes" causing the stupor, which prevent the patient from further suffering. He does [271] not find either in theory or experience reason to believe that these conditions are the result of either suggestion or "fixed ideas." He thinks it natural that the last symptom of the stupor to disappear should be mutism, as speech and vision are the prime factors in communicating with environment. [As has been noted frequently in this book, mutism is a common residual symptom of the benign stupor.] ”

“ Fundamentally, there is a wide divergence between the two processes, in that in the hysterical form a dissociation of consciousness takes place, the patient living in a reminiscent, imaginary or artificially suggested environment, while in a true stupor there is a withdrawal of interest as a whole and a consequent diffuse reduction of all mental processes. ”

“ Her negativism went beyond ordinary limits in that it affected the expression of the face.
When we consider these three cases together, we see that what would otherwise have been deep stupors with profound inactivity, were modified by activity in two directions: suicidal and resistive. Presuming that the symptoms of stupor are all interrelated, we can see a reason why the affect should [66] also have been altered. When one is modified, this should influence the other. When the activity is increased, the emotional concomitants of impulsive acts tend to break through as well. ”

“ In the most pronounced stupor we have evidently a more or less complete standstill in thinking processes. Practically no impressions are registered and consequently nothing is remembered except events that occurred in some short periods when some affective stimulus, or a brief burst of elation, lifts the patient temporarily out of the deep stupor. It is impossible to say whether the statement of a complete standstill has to be qualified. ”

“ 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. ”