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
who has found no other solution than regression for the predicament in which he is. There is nothing specific in the cause of this unhappiness. At times the factors producing it are mainly environmental; at others, the problem is essentially of the patient's own making. Of course almost any type of functional psychosis may emerge from such a state of dissatisfaction, but it is important to note that unlike manic states, for instance, stupors invariably develop from a situation of unhappiness. Quite frequently the choice of the stupor regression is determined by some definitely environmental event which suggests death. This often comes as the actual death of the patient's father (in the case of a woman) or employer, events which inflate the already existing, although perhaps unconscious, desire for mutual death. Again, the precipitating factor may be a situation which adds still another problem and makes the burden of adaptation intolerable, forcing on him the desire for death. In these cases the actual psychosis is sometimes ushered in dramatically with a vision of some dead person (often a woman's father) who beckons, or there are dream-like experiences of burial, drowning, and so on.
A few cases taken at random from our material exemplify these features of the unhappiness in which the psychosis appears as a solution with its development of the death fancy.
Alice R., at the age of 25, was much troubled by worrying over her financial difficulties and the
shame of an illegitimate child. Retrospectively she stated, "I was so disgusted I went to bed—I just gave up hope." Shortly before admission she said she was lost and damned, and to the nurse in the Observation Pavilion she pleaded, "Don't let me murder myself and the baby."
Caroline DeS. (Case 2) for some time was worried over the engagement of her favorite brother to a Protestant (herself a Catholic) and the threatened change of his religion. At his engagement dinner she had a sudden excitement, crying out, "I hate her—I love you—papa, don't kill me." This excitement lasted for three weeks, during two of which she was observed, when she spoke frequently of being killed and going to Heaven. The conflict was frankly stated in the words, "I love my father but don't want to die." Then for two weeks she had some fever, was tube-fed, muttered about being killed or showed some elation, there being apparently interrupted stuporous, manic and, possibly, anxiety episodes. Finally she settled down to a year of deep stupor.
Laura A. had for three months poor sleep with depression over her failure in study. Another cause for worry was that her father was home and out of work. She reached a point where she did not care what happened but continued working. Ten days before admission she was not feeling well. The next morning she woke up confused and frightened, speedily became dazed, stunned, could not bring anything to her memory. This rather sudden
stupor onset was not accompanied by any false ideas, at least none which the family remembered.
Mary C. (Case 7) was an immigrant who felt lonely in the new country. Two weeks before admission her uncle with whom she was living died. She thought she had brought bad luck, complained of weakness and dizziness, then suddenly felt mixed up, her "memory got bad," and she thought she was going to die. Next she was frightened, heard voices, thought there was shooting and a fire. For a short time she was inactive and later began shouting "Fire!" When taken to the Observation Pavilion, she was dazed, uneasy, thought she was on a boat or shut up in a boat which had gone down; all were drowned. Then came a mild stupor.
Maggie H. (Case 14), while pregnant, fancied that her baby would be deformed and that she would die in childbirth. Three weeks before admission this event took place. For five days she worried about not having enough milk, about her husband losing his job (he did lose it) and thought her head was getting queer. On the fifth day she cried, said she was going to die, that there was poison in the food, that her husband was untrue to her. She became mute but continued to attend to her baby. She saw dead bodies lying around, and by the time she was taken to the Observation Pavilion was in a marked stupor.