[6] Kirby, loc. cit., pointed out that stupor showed resemblance to feigned death in animals, that the reaction suggested a shrinking from life and that ideas of death were common.
[A] We may mention that since this study was made we risked a prediction of stupor, which events justified, in the case of a patient who showed expectation of death without affect. Such opportunities are rare, however, since we usually do not see these cases till the stupor symptoms are manifest. It would be unsafe to dogmatize on the basis of such meager material.
CHAPTER VI
AFFECT
The most constant and significant symptom in the stupor reaction is the change in affect. This extends from mere quietness in the mildest phases of the disease through the stage of indifference where apathy replaces the normal reactions of the personality, to the final condition of complete inactivity in the vegetative stupor where all mental life seems to have ceased. It seems as though there were, as a pathognomonic sign of the morbid process, a lack of energy and loss of the normal élan vital.
We may say, in fact, that the establishment of a specific type of emotional change is justification for classifying all milder stupor reactions with the deep stupors. In other words, our reason for the enlargement of the stupor group to include all apathetic reactions (except those of dementia præcox) is the belief that this dulling of the emotional response is as specific a type of emotional change as is anxiety, depression or elation. Perhaps it would be more accurate to say that this clinical group is founded on the symptom complex which is built around apathy. There is never any resemblance between apathy and the mood of elation or anxiety.
A discrimination from depression is the only differentiation worth discussion.
The first point that should be made is that there is a difference between marked depression and the mood of stupor. In the former we get a retardation with a feeling of blocking, rather than of an absence of energy. The expression of the patient is one of dejection, not of vacancy, which bespeaks a mood of sadness, even when the patient is so retarded as to be mute and therefore incapable of describing his emotions. 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. The stuporous case, on the other hand, evidences merely less and less indifference, and more and more interest in his environment and in himself as he gets well.
The associated symptoms are no less dissimilar. The difficulty in thinking which troubles the depressed patient is slight in proportion to his emotional gloom, and he feels himself to be much more incompetent intellectually than examination proves him to be. On the other hand, in the stupor reac
tion we find that the thinking disorder runs hand in hand with the apathy and that the intellectual capacity of the patient is really markedly interfered with, as can be shown by more or less objective tests. 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. This actual thinking disorder is not present in those forms of manic-depressive insanity which are characterized by elation, anxiety or depression but is seen only in stupors, occasionally in absorbed manic states (manic stupor) and sometimes in perplexity states. The psychological mechanisms of this last group are probably analogous to those of stupor, but this is not the place for a discussion of this topic.