She recovered completely about six and a half months after her admission.
If we consider together the common features of these three cases, we see that they resemble stupors only in the presence of inactivity and apparent apathy. It is true that death appears in the ideational content but not with that prominence, bordering on exclusiveness, which characterizes such delusions in the true stupors. These three patients give one the impression of being absorbed in thoughts that have many variations. It seems as if they had difficulty in grasping the facts of the environment, while feeling at the same time the vividness of the changing internal thoughts, hence a confusion develops which is either subjective, objective, or both.
It is probably the introversion of attention which gives rise to the apparent apathy, because normal emotions emerge as part of our contact with reality around us. This lack of contact with the environment leads also to inactivity. If one's attention and interest is turned inwards, there can be no evidence of mental energy exhibited until the patient is roused to contact with the people or things about him. It is noteworthy that in these cases emotional expression emerged when the patients were stimulated to some productiveness in speech.
These conditions really constitute a different psychosis in the manic-depressive group, essentially they are perplexity states such as have recently been described by Hoch and Kirby.[7] Not infrequently we see exhibitions of this tendency in what are otherwise typical stupors. For example, Mary F. (Case 3) (the third case to be described in the first chapter), showed for a few days after admission a condition when she was essentially somewhat restless in a deliberate aimless way. At the same time she looked dazed or dreamy. With this restlessness she appeared at times "a little apprehensive." Although she spoke slowly, with initial difficulty she answered quite a number of questions. Her larval perplexity was evidenced by the doubt expressed in a good many of her utterances, such as, "Have I
done something?" "Do people want something?" "I have done damage to the city, didn't I?" When asked what she had done, she said, "I don't know." She asked the physician, "Are you my brother?" and when questioned for her orientation said, "Is not this a hospital?" The atmosphere of perplexity also colored the information which she did recall correctly; for instance, when asked her address, she said, "Didn't I live at ——?" then giving the address correctly.
As stated in Chapter V dealing with the ideational content of stupor, one has to look on the delusions of patients as symptoms subject to analysis and classification just as truly as the variations in mood or intellectual processes, in fact they should be subject to the same correlation as are the mental anomalies which are usually studied, particularly if we are to understand these psychoses as a whole. Let us, therefore, consider the death ideas in the three cases studied in this chapter. We find that, as in the ordinary stupors, there are delusions of death, also of mutual death (with the father), but there is a tendency to elaboration so that the death is only part of a larger Œdipus drama, the rest of which is usually lacking in stupors. Here it is present. So we have thoughts of the death of the mother or husband, another rival, considerable preoccupation with Heaven, and also erotic fancies.
We find in manic-depressive insanity a tendency for more or less specific ideational contents with dif
ferent types of the psychoses.[8] For example, there are religious and erotic fancies or ambitious schemes dominating the thoughts of manic patients, fears of aggression and injury met with in anxiety cases, and so on. In stupors, death seems to be a state of non-existence with other meanings lacking or only hinted at occasionally. When it tends to be elaborated, it leads over to formulations suggesting personal attachments and emotional outlet, and then we are apt to find interruptions of the pure stupor picture. For example, Charlotte W. (Case 12), whose case has been described, thought much about being in Heaven and ended with a hypomanic state. Atypical symptoms appear just as constantly in these cases, as do the atypical ideas. In other words, the thought content is definitely correlated with the clinical picture.
As the clinical pictures show the relationship of stupor to other psychoses, so there is also a correlation with varying formulations of the death fancy. 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
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. Such theories tend to justify the view of essential unity of the manic-depressive group.