[*] Read at the sixth annual meeting of the American Psychopathological
Association, May 5, 1915, New York City.
JOHN T. MACCURDY, M. D. Psychiatric Institute, Ward's Island
and
WALTER L. TREADWAY, M. D. Assistant Surgeon, U. S. Public Health Service
MOST psychiatrists state or tacitly assume that dementia praecox is a disease of a steadily progressive nature, where the first symptom of dementia is a signal for relentless degradation of the patient's mental capacity except in the sphere of the more mechanical, intellectual functions. Yet the experience of every institutional physician denies the universality of this deterioration, and the statistics in any good text book demonstrate that many cases are "chronic" rather than "deteriorating." Woodman[1] has made a careful study of 144 such chronic cases, and shows what a surprisingly large proportion of these develop a good adaptation to the artificial environment of the institution. So far as we know, however, no one has attempted to formulate any definite features of onset which could be taken as a guide in determining the gravity of the mental derangement. In fact Bleuler states categorically that "up to the present no correlation has been discovered between the symptoms of onset and the gravity of the outcome." Kraepelin has split off from dementia praecox a separate psychosis—Paraphrenia systematica—which he timidly defends as a clinical entity apparently because the course is a long one and the deterioration less marked than in dementia praecox. But he gives us no concise prognostic data; in fact one feels on reading his paper that the diagnosis must be made post hoc. This problem is manifestly of equal importance from the social and the scientific standpoint: until we can predict the outcome our treatment must be empiric and palliative; we confess ourselves ignorant of the disease process if we cannot make a prognosis.
[1] R. C. Woodman, N. Y. State Hospital Bulletin, Vol. II, No. 2, 1909.
It is possible to make certain a priori speculations as to prognostic criteria based on classification and what that implies. We know that pure paranoia is not a deteriorating psychosis—that it does not necessarily preclude the possibility of considerable social usefulness—and that it grades off almost imperceptibly into dementia praecox. The features differentiating these two diseases should therefore supply us with data for determining the prognosis. A case undoubtedly, praecox, which shows markedly the differential features of paranoia, should have a proportionately better outlook. In a vague way our common sense uses this standard when it makes us "feel" that the case will have a long course which shows a relatively well retained personality in conjunction with praecox symptoms. But "feelings" are hardly objective criteria. What symptoms may we make use of? We may say that the praecox patient as opposed to the paranoia has a poverty or inappropriateness of affect, a scattering of thought and a lack of systematization in his delusions. The weakness of will on which Kraepelin lays so much stress may be included, though that can probably be derived from the scattering of thought. What of these symptoms may be analyzed for our purpose? Affect changes and dissociation in the stream of thought are themselves signs of the deterioration we wish to predict; to make use of them we should have at hand some theory as to the relation between their quality and quantity, and that we have not. There remains the content of the psychosis, a definitely objective material with which to work. This is naturally a big problem—almost as wide as insanity itself—and one brief communication cannot pretend to solve it. What we wish to do is merely to put forward tentatively the claim of one type of delusion formation to prognostic value.
Now if delusions are to be an index to deterioration they must in some way hold a mirror to the changes in the personality, repeat them or prefigure them. If we generalize our conception of functional dementia, we can say that one of its most striking features is a destruction of the faculty of appropriate reaction, a loss of what one may term the sense of reality. The patient in direct proportion to the degree of his dementia loses his capacity to recognize the reality of his environment or his relationship to it, and builds up more and more a world of his own in which he lives untroubled by the demands of adaptation. No one who has ever argued with a paranoic will forget how keen a sense of reality he may retain, how logical his arguments are, and how reasonable his delusions appear, if only some one point be granted. With the praecox, however, the opposite impression may be quite as striking. His delusions are bizarre, inconsistent, kaleidoscopic; he has no logical explanation and cannot even state them consecutively. And all gradations from pure paranoia to dementia praecox seem to have corresponding losses in the sense of reality as embodied in delusions.
May we not hope to find in the content of the psychosis some objective criterion as to the degree in which the sense of reality is lost, with all that it implies?
But what takes the place of the sense of reality or what causes it to go? With what tendency of the psychotic individual is it in conflict? The answer is a psychological truism—the indulgence in fancies. Imagination, of course, is essential to every human being, no purposeful action can be instituted without its first being carried out in imagination. Phantastic thinking begins when the subject fails to apply the test of reality to his mental image and exclude it if it be not adapted to realization. If environment or internal inhibitions prevent this realization, however, the craving: lying back of the fancy must be diverted to a more practical channel—the normal solution—or the fancy must persist in spite of its impracticability. This latter process is the germ of the psychosis. But not its development. A certain compromise may be reached—he who digs for gold in his back-yard is not so crazy as he who reaches out his hand for the moon. Nor is the paranoic who chooses to put his interpretation on the surliness of his employer as far estranged from reality as the praecox who recognizes his employer in the person of the physician. The content of the psychosis may then express the relative strength of the two antagonistic factors, sense of reality and fancy, the two factors whose relative importance decide the issue for sanity or insanity.