Footnotes:
[11] The reader will note that this view is opposed to that of Kraepelin, who has written largely on so-called "mixed conditions" in manic-depressive insanity. We believe that careful clinical studies confirm our opinion and that his classification is based on less thorough observation and analysis. This subject will be discussed at greater length in a forthcoming book on "The Psychology of Morbid and Normal Emotions," by Dr. MacCurdy.
CHAPTER XI
MALIGNANT STUPORS
As we have seen, the benign stupors are characterized by apathy, inactivity, mutism, a thinking disorder, catalepsy and negativism. All these symptoms are also found in the stupors occurring in dementia præcox. In fact this symptom complex has usually been regarded as occurring only in a malignant setting. There can be no question about the resemblance of benign to dementia præcox stupors. Even such symptoms as poverty and dissociation of affect, usually regarded as pathognomonic of dementia præcox, have been described in the foregoing chapters. Either recovery in our cases was accidental or there is a distinct clinical group with a good prognosis. If the latter be true, the symptoms must follow definite laws; if they did not, we would have to abandon our principles of psychiatric classification. Naturally, then, we seek to find the differences between the cases that recover and those that do not. There is never any difficulty in diagnosis where a stupor appears as an incident in the course of a recognized case of catatonic dementia præcox. We shall therefore consider only such clinical pictures as resemble those described in this book, in that the
symptoms on admission to a hospital or shortly after are those of stupor. It should be our ambition to make a positive diagnosis before failure to recover in a reasonable time leads to a conclusion of chronicity.
It is probably safe to assume, on the basis of as large a series as ours, that the symptoms of stupor per se imply no bad prognosis. Further, it has been noted that a relatively pure type of reaction is seen, the symptoms appearing with tolerable consistency. In analyzing the histories of dementia præcox patients, therefore, one looks for inconsistencies among, or additions to, the stupor symptoms. We may say at the outset that we have been able to find no case of malignant stupor that showed what we regard as a typical benign stupor reaction, and it is questionable whether partial stupor as we have described it, ever occurs with a bad prognosis. Usually the discrepant symptoms in the dementia præcox cases are sufficiently marked to enable one to make a positive diagnosis quite soon after the case comes under observation.
The law of benign stupor is a limitation of energy, emotion and ideational content. In dementia præcox we have a re-direction of attention and interest to primitive fantastic thoughts and a consequent perversion of energy and emotion. In many malignant stupors one can detect evidence of this second type of reaction in symptoms that are anomalous for stupor. For instance, one meets with frequent silly and inexplicable giggling. Then, too, smiling,
tears or outbursts of rage, the occasions for which are not manifest, are much more frequent than in typical stupor. Similarly, delusional ideas (not concerned with death at all) may appear or the patient may indulge in speech that is quite scattered, not merely fragmentary. Two cases may be cited briefly to illustrate these dementia præcox symptoms superadded to those of stupor.
Case 20.—Winifred O'M. Age: 19. Single. Admitted to the Psychiatric Institute May 6, 1911.