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
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. Similarly what we remember seems to be that which we associate with the impressions received by an active consciousness. Actual events persist in memory better than those of fancy, in proof of which one thinks at once of the vanishing of dreams on waking, with its reëstablishment of extroverted consciousness. This registration of impressions requires interest and active attention. Without interest there is no attention and no registration. The patient in stupor presents just the memory defect which we would expect. Indifference to his environment leads to a poor memory of external events, while on recovery there may be such a divorce between consciousness of normal and abnormal states that the past delusions are wiped from the record of conscious memory. Withdrawal of energy then produces not only inactivity and apathy but grave defects in intellectual capacity.
The natural flow of interest in regression is to earlier types of ambition and activity. This is betrayed not merely by the thought content dealing with the youth and childhood of the patient, but also is manifested in behavior. Excluding involution
melancholia there is probably no psychosis in which the patients exhibit such infantile reactions as in stupor. Except for the stature and obvious age of these patients, one could easily imagine that he was dealing with a spoiled and fractious infant. One thinks at once of the negativism which is so like that of a perverse child and of the unconventional, personal habits to which these patients cling so stubbornly. Masturbation, for instance, is quite frequent, while willful wetting and soiling is still more common. We sometimes meet with childishness, both in vocabulary and mode of expression. In one case there was evidently a delusion of a return to actual childhood, for she kept insisting that she was "in papa's house."
The frequency with which the delusion of mutual death occurs in stupor is another evidence of its regressive psychology. The partner in the spiritual marriage is rarely, if ever, the natural object of adult affection, but rather a parent or other relative to whose memory the patient has unconsciously clung for many years, reawakening in the psychosis an ambition of childhood for an exclusive possession that reaches its fulfillment in this delusion. Closely allied with this is another delusion, that of being actually dead, which the patients sometimes express in action, even when not in words. The anesthesia to pin pricks, the immobility and the refusal to recognize the existence of the world around, in patients who give evidence of some intellectual operations still persisting, are probably all part of a feigned
death, with the delusion expressing itself in corpse-like behavior.
Finally we must consider the meaning of the deep stupor where no mentation of any kind can be proven and where none but vegetative functions seem to be operating. This state is either one of organic coma, in which case it marks the appearance of a physical factor not evidenced in the milder stages, or else it is the acme of this regression by withdrawal of interest. As has been stated, back of the period of primitive childish ideas there lies a hypothetical state of mental nothingness. If we accept the principle of regression we find historically an analogue to what is apparently the mental state of deep stupor in the earliest phases of infancy. This view receives justification from the study of the phenomenon of variations in symptoms. Mental faculties at birth are larval, and if such condition be artificially produced mental activity must be potentially present (as it would not be if we were dealing with coma). In Chapter IV phenomena of interruption of stupor symptoms were detailed. One case that was mentioned is now of particular importance as demonstrating that an appropriate stimulus may dispel the vacuity of complete stupor by raising mental functions to a point where delusions are entertained. This patient retrospectively recalled only certain periods of her deepest stupor, occasions when she was visited by her mother. At these times, as she claimed, she thought she was to be electrocuted and told her mother so, adding, "Then it
would drop out of my mind again." Otherwise her memory for this state was a complete blank. Here we see a normal stimulus producing not normality but something on the way towards it, that is, a condition less profound than the state out of which the patient was temporarily lifted.
This case exemplifies the principle of levels in the stupor reaction which we have found to be of great value in our study. These levels are correlated with degrees of regression, as a review of the symptoms discussed above may show. In the first place, the dissatisfaction with life, the first phase of regression, leads to the quietness—the inactivity and apathy, which are the most fundamental symptoms of the stupor reaction as a whole. Initiative is lost and with this comes a tendency for the acceptance of other people's ideas. That is the probable basis for the suggestiveness which we concluded was a prominent factor in catalepsy. Indifference and stolidity may exist with those milder degrees of regression which do not conflict with one's critical sense, and hence may be present without any false ideas. The next stage in regression is that where the idea of death appears. Although not accepted placidly by the subject, its non-acceptance is demonstrated by the idea being projected—by its appearance as a belief that the patient will be killed. This notion of death coming from without has again two phases, one with anxiety where normality is so far retained that the patient's instinct of self-preservation produces fear, and a second phase where this in
stinct lapses and the patient so far accepts the idea of being killed as to speak of it with indifference. The next step in regression is marked by the spoiled-child conduct, interest being so self-centered as to lead to autoerotic habits and the perverse reactions which we call negativism. When death is accepted but mental function has not ceased, the latter is confined to a dramatization of death in physical symptoms or to such speech and movements as indicate a belief that the patient is dead, under the water, or in some such unreal situation. Finally, when all evidence of mentation in any form is lacking, we see clinically the condition which we know as deep stupor and which we must regard psychologically as the profoundest regression known to psychopathology, a condition almost as close to physiological unconsciousness as that of the epileptic.