CHAPTER XIV
SUMMARY OF THE STUPOR REACTION
Having discussed in detail the various symptoms and theoretic aspects of the benign stupors, it may be well to have these observations and speculations summarized.
It being established that stupors occur as a temporary form of insanity[12] psychiatry is faced at once with the problem of describing these conditions accurately in order to ascertain their nosological position. To this end we first examined typical cases of deep stupor and found that the clinical picture is made up of the following symptoms: In the foreground stands poverty of affect. The patients are almost unbelievably apathetic, giving no evidence by speech or action of interest in themselves or their environment, unmoved even by painful stimuli. Their faces are wooden masks; their voices as colorless when words are uttered. In some cases sudden mood reactions break through at rare intervals. The second cardinal symptom is inactivity. As a rule there is a complete cessation of both spontaneous and reactive movements and speech. So profound may this
inhibition be that swallowing and blinking of the eyes are often absent. The trouble is not a paralysis, however, for reflexes without psychic components are unaffected. Possibly related to the inactivity is the preservation of artificial positions which is called catalepsy, a fairly frequent phenomenon. A tendency opposite to the inactivity is seen in negativism. This perversity is present in all gradations from outbursts of anger with blows and vituperation to sullen, or even emotionless, muscular rigidity. This last occurs most often when the patient is approached but may be seen when observations are made at a distance. Frequently wetting and soiling are due to negativism, when the patient has been led to the toilet but relaxes the sphincters so soon as he leaves it. A constant feature is a thinking disorder. On recovery memory is largely a blank even for striking experiences during the psychosis and, when accessible during the stupor to any questioning, a failure of intellectual functions is apparent. An ideational content may be gathered while the stupor is incubating, during interruptions, or from the recollections of recovered patients. Its peculiarity is a preoccupation with the theme of death, which is not merely a dominant topic but, often, an exclusive interest. Probably to be related to this is a tendency, present in some cases, to sudden suicidal impulses, that are as apparently planless and unexpected as the conduct of many catatonics. Finally the disease is prone to exhibit certain physical peculiarities. A low fever
is common and so are skin and circulatory anomalies. A loss of weight is the rule, and menstruation is almost always suppressed.
As to the frequency of stupor no figures are available, for the simple reason that the diagnosis in large clinics has not been made with sufficient accuracy to justify any statistics. Most of these cases are usually called catatonia, depression, allied to manic-depressive insanity or allied to dementia præcox. The majority of the stupors reported in this book were in women, but this is merely the result of chance, since it has been easier in the Psychiatric Institute to study functional psychoses in the female division, while the male ward has been reserved largely for organic psychoses. The majority of the patients seem to be between 15 and 25 years of age, so that it is, presumably, a reaction of youthful years. In our experience most cases occur among the lower classes, which agrees with the opinion of Wilmanns who found this tendency among prisoners.
This gives a brief description of the deep stupor. But even our typical cases did not present this picture during the entire psychosis. They showed phases when, superficially viewed, they were not in stupor but suffered from the above symptoms as tendencies rather than states. There are also many psychoses where complete stupor is never developed. This gives us our justification for speaking of the stupor reaction, which consists of these symptoms (or most of them) no matter in how slight a
degree they may be present. The analogy to mania and hypomania is compelling. The latter is merely a dilution of the former. Both are forms of the manic reaction. We consequently regard stupor and partial stupor as different degrees of the same psychotic process which we term the stupor reaction. To understand it the symptoms should be separately analyzed and then correlated.
The most fundamental characteristic of the stupor symptoms is the change in affect which can be summed up in one word—apathy. It is fundamental because it seems as if the symptoms built around apathy constitute the stupor reaction. The emotional poverty is evidenced by a lack of feeling, loss of energy and an absence of the normal urge of living. This is quite different from the emotional blocking of the retarded depression, for in the latter the patient shows either by speech or facial expression a definite suffering. The tendency to reduction of affect produces two effects on such emotions as internal ideas or environmental events may stimulate. Exhibitions of emotion are either reduced or dissociated. For instance, anxiety is frequently diminished to an expression of dazed bewilderment; or, isolated and partial exhibitions of mood occur, as when laughter, tears or blushing are seen as quite isolated symptoms. This latter—the dissociation of affect—seems to occur only in stupor and dementia præcox. It should be noted, however, that inappropriateness of affect is never observed in a true benign stupor. A final peculiarity is the tendency to