We owe our knowledge of these disorders to the contributions of Reich, Moeli, Kutner, Ganser, Rish and others, authors who, although describing a more or less identical symptom-complex, have given to it different names, such as hysterical stupor, Ganser symptom-complex, catatonia of degenerates, etc. The distinguishing features of this disorder are its psychic origin, that is, its development in consequence of some strongly affective experience, and its high grade of impressionability to things in the environment which may at any time suddenly cause a complete transition from deep stupor to normal manner and behavior.
The symptomatology consists of an acute delirioid, hallucinatory episode, usually followed by a more or less complete amnesia which may go back far enough to include the experience which provoked the disorder. Such delusional formation as takes place after the disappearance of the fulminant symptoms may well be considered as part of the repair process, a mechanism which in most instances reflects the individual’s endeavor to adjust himself to an unpleasant, unbearable situation, and must not be looked upon necessarily as an indication of the progressiveness of the disorder.
As we have stated before, complete correction of all delusional ideas may suddenly take place upon the removal of the causative factor at the bottom of the entire situation.
As to the treatment of this acute prison psychotic complex theoretically, we should have no difficulty in deciding this question. We are dealing with the sequelæ of some definite situation, and the removal of that situation may be, and actually is, in most instances, sufficient to bring about recovery. When we come, however, to deal with concrete instances in daily practice, the problem does not lend itself so easily to solution.
What of the man who upon being arrested following the commission of murder, develops a psychosis while awaiting trial, or who having been found guilty of murder develops a psychosis while awaiting execution? The first question which the psychiatrist is called upon to decide in many instances is that of malingering. To the lay mind and to the minds of many of our eminent—but psychiatrically uninformed—jurists the question of malingering suggests itself at once. To them it is perfectly evident that this development of a mental disorder, in the wake of a criminal act, is nothing but a timely preparation for the “insanity dodge.” The clinical pictures presented by the acute prison psychosis are especially apt to awaken suspicions of malingering in the minds of the untrained. We see individuals who apparently never before showed any evidence of mental disorder, and who immediately following the commission of a criminal act manifest pictures of grave alienation. Many of them don’t know how much twice two is, are absolutely ignorant of the most elementary subjects, remember nothing of the deed, and most important of all fashion their deliria in such a way as to entirely negate the deed, or at any rate justify it.
But why cannot all these manifestations be genuine? Many of us no doubt recall the effect which examinations have upon certain students. The emotional accompaniment of the examination, especially the emotion of fright, causes many a student to forget facts which he knew as well as his own name, and which he is able readily and fully to recollect as soon as the examination is over. Are we to assume that these students are malingering? Decidedly not. Why then should we question at all the genuineness of a mental disorder developing in an individual who faces the gallows or a life-long imprisonment? As a matter of fact cases of pure malingering are among the rarest things which the psychiatrist observes. Wilmanns,[1] in his study of 277 cases of insanity of prisoners, found but two cases of simulation, and in a later review of the diagnoses of the same series of cases, the two cases of malingering do not appear at all. Bonhoeffer[2] in a study of 221 cases of insane criminals found 0.5 per cent of malingerers. This is the experience of everyone who comes in contact with these cases, and there are others who go so far as to maintain that every malingerer of mental symptoms is mentally defective.
But let us assume that we have succeeded in convincing those concerned of the genuineness of the disease at hand; what line of treatment should be recommended? In the first place, we must remember that the mental disorder, if it belongs to the group we are discussing here, is the result of a criminal act, and following in its wake, and that therefore the plea of insanity as an excuse for the deed must manifestly be excluded. But may not this type of reaction furnish us an index to the original personality of the culprit? In other words, should we consider an individual absolutely normal, if, in reaction to some stressful situation, he breaks down mentally and develops a psychosis? The majority of authorities maintain that these individuals are decidedly abnormal, and that it is only a poorly-knit organism which permits of that sort of reaction. Birnbaum,[3] for instance, insists that the possibility of a psychic incitation of a mental disorder is the criterion of a degenerative soil. This is undoubtedly too extreme a view, but the more one observes these cases, the more one is inclined to hesitate in calling these individuals normal in the accepted sense of the term. Let us assume for the moment that these psychotic reactions are indices of an abnormal personality. Is this defect of sufficient import to render the individual irresponsible in the eyes of the law? This question, I fear, cannot be answered very readily. Looking at it from a purely juridical standpoint, we must say no; because an individual is so loosely organized as to break down mentally under a given stress, does not at all imply that a knowledge of the difference between right and wrong is excluded. The jurist is willing to concede to the proposition of a poorly-organized nervous system, a degenerative make-up, a psychopathic constitution; but if these defects are such as to manifest themselves in crime, society must be given the inalienable right to protect itself from such defectives. The result is that either no extenuating circumstances are considered at all, and the individual is dealt with in the ordinary way, or he is adjudged insane and committed to a hospital for the criminal insane, whether or no insanity exists at the time of trial. Thus we have on the one hand a prison population which more properly belongs under the régime of a hospital, while on the other hand, we insist on keeping individuals locked up in hospitals for the insane, whether or no they show actual psychotic symptoms. If one of the latter class endeavors to obtain his release by habeas corpus, a tremendous howl is immediately raised by the public about the “insanity dodge”, the worthlessness of expert testimony and the unpardonable offense of letting loose upon society a dangerous criminal. If we stop to consider for a moment, we must admit that in the great majority of instances, we are not dealing here with dangerous criminals. The man who as a result of a series of overwhelming circumstances over which he had little or no control, kills another in a fit of passion, is not necessarily a dangerous criminal. In the majority of cases it is fair to assume that such an individual will never again in his life have to cope with a similar set of circumstances. The great majority of these people have led, up to that single crime of their life, an honest, peaceful existence, and the instances of an accidental criminal turning recidivist are extremely rare.
Society looks on complacently at the repeated sentencing of the habitual criminal and watches without alarm the never failing phenomenon of how each successive imprisonment only serves to deprave him more profoundly; it never considers the danger of letting this type of criminal loose to prey upon it; just so he has served his just and legally prescribed sentence. But let the victim of the “insanity dodge” prejudice endeavor to gain his freedom, and society is at once up in arms.
Thus the matter stands, and until the public learns to know its criminals as they actually are, this problem will remain unsolved. The prognosis of the acute prison psychotic complex is good in the majority of instances. The removal to a hospital régime usually serves to put a stop to the process and it is important for the expert witness to bear this in mind for obvious reasons.
We have thus far discussed the psychoses developing in prisoners awaiting trial, and we shall now turn to that group of cases which are sent to us from penal institutions which serve for the confinement of the convicted criminal.