Naturally we do not see individual cases in which all these stages appear successively, each sharply defined from its predecessor. To expect this would be as reasonable as to look for a man whose behavior was determined wholly by his most recent experience. Any psychologist knows that every human being behaves in accordance with influences whose history is recent or represents the habit of a lifetime. At any given minute our behavior is not simply determined by the immediate situation, but is the product of many stages in our development. Quite similarly we should not expect in the psychoses to find evidences of regression to a given period of the individual's life appearing exclusively, but
rather we should look for reactions at any given time being determined preponderantly by the type of mentation characteristic for a given stage of his development. As a matter of fact, we see in psychoses, particularly in stupor, more sharply defined regressions to different levels than we ever see in normal life.
Our psychological hypothesis would be incomplete and probably unsound if it could not offer as valid explanations for the atypical features in our stupor reactions as for the typical. The unusual features which one meets in the benign stupors are ideas or mood reactions occurring apparently as interruptions to the settled quietude or in more protracted mild mood reactions, such as vague distress, depression or incomplete manic symptoms, which have been described in the chapter on affect. The interruptions are easily explained by the theory of regression. If stupor represents a complete return to the state of nothingness, then the descent to the Nirvana or the re-ascent from it should be characterized by the type of thinking with the appropriate mood which belongs to less primitive stages of development. A review of our material seems to indicate that there is a definite relationship between the type of onset and the character of the succeeding stupor. For instance, in the cases so far quoted in this book, the onsets characterized by mere worry and unhappiness and gradual withdrawal of interest had all of them typical clinical pictures. On the other hand, of those who began with reactions of definite
excitement, anxiety or psychotic depression, there were interruptions which looked like miniature manic-depressive psychoses in all but one case. This would lead one to think that these patients retraced their steps on recovery or with every lifting of the stupor process, moved slightly upward on the same path on which they had traveled in the first regression. The case of Charlotte W. (Case 12), which is fully discussed in the chapter on Ideational Content, offers excellent examples of these principles.
The next atypical feature is the phenomenon of reduction or dissociation of affect, the frequency of which is mentioned in Chapter V. As the law of stupor is apathy, normal emotions should be reduced to indifference and no abnormal moods, such as elation, anxiety or depression, should occur. What often happens is that these psychotic affects appear but incompletely, often in dissociated manifestations. This looks like a combination of two psychotic tendencies, the stupor reduction process which inhibits emotional response and the tendency to develop abnormal affects which characterize other manic-depressive psychoses. There is no general psychological law which makes this view unlikely. One cannot be anxious and happy at the same instant, although one can alternate in his feelings; but one can fail to react adequately to a given stimulus when inhibited by general indifference. In fact it is because apathy is, properly speaking, not
a mood but an absence of it, that it can be combined with a true affect. It is possible, therefore, to have a combination of stupor and another manic-depressive reaction, while the others cannot combine but only alternate.[11]
Finally we must discuss the psychological meaning of cases, such as those described in Chapter VIII, where we concluded that there were psychoses resembling stupors superficially. It seemed likely that these patients were absorbed in their own thoughts, rather than being in a condition of mental vacuity. It is not difficult to explain the objective resemblance. All evidence of emotion (apart from subjective feeling tone which the subject may or may not report) is an expression of contact with the outer world. There must be externalization of attention to environment before a mood becomes evident. A moment's reflection will show this to be true, for no further proof is needed than the phenomena of dreaming. The attention being given wholly to fantasies, the subject lies motionless, mute and placid, although passing through varied autistic experiences. Only when the dream becomes too vivid, disturbs sleep and re-directs attention to the environment—only then is emotion objectively
betrayed. There is an appearance of apathy and mental vacuity which the dreamer can soon declare to be false. He was feeling and thinking intensely. In any condition, therefore, such as that of perplexity or of an absorbed manic state, the patient may be objectively in the same condition as a typical stupor. The histories of the two psychoses differentiate the two reactions which may be indistinguishable at one interview. The keynote of one reaction is indifference, while that of absorption is distraction, a perversion of attention to an inner, unreal world.
In summary we may recapitulate our hypotheses. Stupor represents, psychologically speaking, the simplest and completest regression. Adaptation to the actual environment being abandoned, attention reverts to earlier interests, giving symptoms of other manic-depressive reactions in the onset or interruptions, and finally dwindles to complete indifference. The disappearance of affective impulse leads to objective apathy and inactivity, while the intellectual functions fail for lack of emotional power to keep them going. The complicated mental machine lies idle for lack of steam or electricity. 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
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.