AFFECT
The most constant and significant symptom in the stupor reaction is the
change in affect. This extends from mere quietness in the mildest phases
of the disease through the stage of indifference where apathy replaces
the normal reactions of the personality, to the final condition of
complete inactivity in the vegetative stupor where all mental life seems
to have ceased. It seems as though there were, as a pathognomonic sign
of the morbid process, a lack of energy and loss of the normal _élan
vital_.
We may say, in fact, that the establishment of a specific type of
emotional change is justification for classifying all milder stupor
reactions with the deep stupors. In other words, our reason for the
enlargement of the stupor group to include all apathetic reactions
(except those of dementia præcox) is the belief that this dulling of the
emotional response is as specific a type of emotional change as is
anxiety, depression or elation. Perhaps it would be more accurate to say
that this clinical group is founded on the symptom complex which is
built around apathy. There is never any resemblance between apathy and
the mood of elation or anxiety. A discrimination from depression is the
only differentiation worth discussion.
The first point that should be made is that there is a difference
between marked depression and the mood of stupor. In the former we get a
retardation with a feeling of blocking, rather than of an absence of
energy. The expression of the patient is one of dejection, not of
vacancy, which bespeaks a mood of sadness, even when the patient is so
retarded as to be mute and therefore incapable of describing his
emotions. Running through all the stages of stupor, however, there is an
emptiness, an indifference that is in striking contrast to the positive
pain that is felt or expressed by the depressed patient. It may be
objected, of course, that this apathy really represents the final stage
in the emotional blocking of the depressed individual, but the
development of stupor and recovery from it shows an entirely different
type of process. A deep depression recovers by changing the point of
view from a feeling of unworthiness and self-blame to one of normality.
The stuporous case, on the other hand, evidences merely less and less
indifference, and more and more interest in his environment and in
himself as he gets well.
The associated symptoms are no less dissimilar. The difficulty in
thinking which troubles the depressed patient is slight in proportion to
his emotional gloom, and he feels himself to be much more incompetent
intellectually than examination proves him to be. On the other hand, in
the stupor reaction we find that the thinking disorder runs hand in
hand with the apathy and that the intellectual capacity of the patient
is really markedly interfered with, as can be shown by more or less
objective tests. A mere slowing of thought processes accompanied by
subjective feeling of effort is the limit reached in true depression,
while it is merely the beginning of the intellectual disorder in stupor,
for one meets with retardation symptoms only in the partial stupors. The
slowing in these cases seems to represent an early stage of the
intellectual disturbance which reaches its acme in the mental vacuity
and complete incompetence of the deep stupor, just as slow movements in
the partial stupors seem to represent a diluted inactivity reaction.
This actual thinking disorder is not present in those forms of
manic-depressive insanity which are characterized by elation, anxiety or
depression but is seen only in stupors, occasionally in absorbed manic
states (manic stupor) and sometimes in perplexity states. The
psychological mechanisms of this last group are probably analogous to
those of stupor, but this is not the place for a discussion of this
topic.
Another associated symptom whose manifestations differ in depression and
stupor is that of unreality. In the former there is frequently a feeling
of unreality that is purely subjective, whereas the stupor case does not
usually complain of this but does exhibit a difficulty in grasping the
nature of his environment, which the typical depressive case never has.
The occurrence of other mood reactions than apathy in the same patient
is also characteristic. Manic states (usually hypomanic) frequently
occur during the phase of recovery from the stupor. This is an unusual,
although not unknown, phenomenon in recovery from severe retarded
depressions. The circular cases who swing from depression to elation
usually show the milder types of depressive reaction which would never
be confused with stupor. On the other hand, deep stupors very frequently
are terminated by manic reactions, and if not by such means, recovery
seems to occur merely in virtue of a gradual attenuation of the stupor
symptoms. Rarely do we see a change to depression or anxiety heralding
improvement. This tendency of the stupor reaction to remain pure or
change to hypomania is a peculiarity which seems to put stupor in a
class by itself among the manic-depressive reactions, as all the other
mood reactions frequently change from one to the other.
Although apathy is the central pathognomonic symptom of stupor
conditions, there are other mood anomalies to be noted. One of these is
the tendency for inconsistency in, as well as reduction of, the
expression of emotion. For instance, in the states where one would
expect anxiety during the onset of stupor or in its interruptions,
manifestation of this anxiety is often reduced to an expression of dazed
bewilderment. In the anxiety states associated with stupor one does not
meet with the restlessness and expressions of fear which would be
expected. Quite similarly, when a manic tendency is present, it occurs
either in little bursts of isolated symptoms of elation (such as smiling
or episodic pranks), or some of the evidences of elation which we would
expect are missing. For instance, Johanna S. (Case 13) terminated her
stupor with a hypomanic state which was natural except for her always
wearing an expressionless face. Sometimes laughter occurs alone and
gives the impression of a shallow affect, raising a suspicion of
dementia præcox. In fact, such evidences of affect as do appear in the
course of the stupor are apt to be isolated, queer and “dissociated.” It
does not seem as if the whole personality reacted in the emotion as it
does in the other forms of manic-depressive insanity. For example, we
may think of the resistiveness which is so frequently present when the
patient seems in other respects to be psychically dead. One may recall
the case of Meta S. (Case 15), who, otherwise inert, was occasionally
seen with tears or smiles. Anna G. (Case 1), too, was often seen smiling
or weeping. It was noted once of Charlotte W. (Case 12) that she ceased
answering questions and remained immobile with fixed gaze, but when some
mention was made of her going home she flushed and tears ran down her
cheeks, although no change in the fixedness of her attitude or facial
expression was seen. When Johanna S. was visited by her daughter and was
lying motionless in bed, she slowly extended her hands, apparently tried
to speak, and then her eyes filled with tears. Two days later, at the
end of an interview when she had made a few replies, she settled down
into her usual inactivity and, when further urged to answer, her eyes
filled with tears. Similarly, too, in fairly deep stupor pin pricking
may result in flushing, in tears or an increased pulse rate without the
patient giving any other evidence of the stimulus being felt. These
examples seem to show a larval effort at normal human response which,
failing of complete expression, appeared as single isolated features of
emotion suggesting true dissociation. We should also in this connection
bear in mind the impulsive suicidal acts which occur either as
unexpectedly as the impulsiveness in a true dementia præcox patient, or
in a setting of coarse animal-like excitement that seems quite unrelated
to the personality. One is reminded of the patient who made suicidal
attempts during the period when she shouted like a huckster, giving no
evidence whatever by her expression or the tone of her voice of feeling
anxiety, sorrow or any other normal emotion.
All these queer and larval affective reactions remind one strongly of
dementia præcox. The resemblance of the benign stupor to certain
dementia præcox types is not merely a matter of identity with catatonic
features (catalepsy, negativism). In these anomalous mood reactions it
seems as if there were a definite dissociation of affect, and so there
is. How then can we differentiate these emotional symptoms from the
“dissociation of affect” which is regarded as a cardinal symptom of
dementia præcox? The answer is that this term is used too loosely as
applied to the latter psychosis. It is a particular type of dissociation
which is significant of the schizophrenic reaction, for in it there is
an acceptance of what should be painful ideas evidenced either by
incomplete manifestations of anxiety or depression or actually by
smiling. We never see in dementia præcox the reverse--a painful
interpretation of what would normally be pleasant. It is the pleasurable
interpretation of what is really unpleasant that gives the impression of
queerness in the mood of these deteriorating or chronic cases. In
stupor, on the other hand, although this dissociation takes place, the
mood is never inappropriate, merely incomplete in that all the
components or the full expression of the normal reaction are not seen.
Our description of the mood reactions in stupor would be incomplete if
we omitted to mention the occasional appearance of an emotional attitude
not unlike that seen in many cases of involution melancholia, which
reminds one in turn of the reactions of a spoiled child. The commonest
of these manifestations is resistiveness that may occur when an
examination is attempted, feeding is suggested, or a sanitary routine
insisted upon. One also meets with resentfulness. One patient, who
frequently showed this reaction, explained it retrospectively by saying
that she wanted to be left alone. Quite analogous to this is sulkiness
that occasionally appears. Then we have, particularly as recovery
begins, other childish tricks, such as flippancy in answering questions
or the playing of pranks. Such tendencies naturally lead over to frank
hypomanic behavior.
Finally, a peculiar characteristic of the stupor apathy must be
mentioned. This is its tendency to interruptions, when the patient may
return to life, as it were, for a few moments and then relapse. Such
episodes occur mainly in milder cases or towards the end of long, deep
stupors. It is interesting that the occasion for such reappearance of
affect is frequently obvious. We usually observe them in response to
some special stimulus, particularly something that seems to revive a
normal interest. Visits of relatives are particularly common as such
stimuli, in fact recovery can often be traced to the appearance of a
husband, mother or daughter. It is also important to recognize that with
this revived interest, other clinical changes may be manifest, that the
thinking disorder may, for instance, be temporarily lifted. Helen M.,
for example, when visited by her mother was so far awakened as to take
note of her environment, and remembered these visits after recovery like
oases in the blank emptiness of her stupor. She further remembered that
definite ideas were at such a time in her mind that ordinarily was
vacant. She then had delusions of being electrocuted.
In summary, then, we may say that the _sine qua non_ of the stupor
reaction is apathy in all gradations, and that this apathy is as
distinct a mood change as is elation, sorrow or anxiety. Incidental to
this loss of affect there is a dissociation of emotional response
whereby isolated expressions of mood appear without the harmonious
coöperation of the whole personality which seems to be dead. Thirdly,
there tends to be associated with the stupor reaction a tendency to
childish behavior. Finally, the apathy and accompanying stupor symptoms
may be suddenly and momentarily interrupted. An explanation of these
apparently anomalous phenomena will be attempted in the chapter on
Psychology of the Stupor Reaction.