INACTIVITY, NEGATIVISM AND CATALEPSY
1. INACTIVITY. We must now turn our attention to the other cardinal
symptoms of the stupor reaction, and quite the most important one of
these is the inactivity. It is convenient to include under this heading
both the reduction of bodily movement and the diminution or absence of
speech. This inactivity is, of course, related to the apathy which we
have just been discussing, in fact it is one of the evidences of the
loss of emotion. We presume that a patient is apathetic when there is no
expression in the face and when he does not respond to external stimuli,
whether these be physical or verbal, by movement or by word.
Bodily inactivity is present in all degrees, and in some forty
consecutive cases was recognizable in every one. In its most extreme
form there is complete flaccidity of all the voluntary muscles, and
relaxation of some sphincters. As a result of the latter we see wetting,
soiling and drooling. Even those reflexes which are only partially under
voluntary control, like those of blinking and swallowing, may be in
abeyance; for instance, saliva may collect in the mouth because it is
not swallowed, and tube-feeding is frequently necessary on account of
the failure of the patient to swallow anything that is put into his
mouth. The eyes may remain open for such long periods of time that the
conjunctiva and sclera may become quite dry and ulcerate. In these
extreme cases there is, of course, no response to verbal commands. What
is more striking, no reaction appears to pin pricks, so that it seems as
if consciousness of pain were lost.
This deep torpor does not usually persist indefinitely. The commonest
evidence of some form of consciousness persisting is probably to be seen
in blinking when the eye is threatened or the sclera or cornea actually
touched. A very large number of patients, when otherwise quite inactive,
showed considerable response in their muscular resistiveness, the
phenomena of which will be discussed shortly. The relaxation of the
sphincters is apt to persist even after control of the rest of the body
is exercised to the point of permitting the patient to stand or walk
about.
The first phase of obvious conscious control is seen in those patients
who will retain a sitting posture in bed or in a chair. The next stage
is reached where the stuporous case can be stood upon his feet but
cannot be induced to walk. The next degree is that of walking only when
pushed or commanded. Finally spontaneous movement is observed in which
the inactivity is evidenced merely by a great slowness.
No correlation can be established between restrictions of speech and
motion other than that present in the extremes. With complete inactivity
there is almost always consistent mutism, and perfect freedom of speech
does not, as a rule, appear until the movements are free. In between
these extremes all variations are possible, even the deepest stupors are
occasionally interrupted by one or two words; for instance, a patient
may remain comatose, as it were, and absolutely mute for six months,
then to every one’s surprise say one or two words and relapse into a
year of silence. Again one sees cases where movements have become fairly
free and yet the patient says nothing. This is another example of that
inconsistency in reaction which we have already noted in connection with
the mood or affect.
In so far as inactivity is merely an expression of apathy, its causation
will be considered in connection with the psychology of the stupor
reaction as a whole. In so far as there may be specific factors,
however, it may be of interest to consider what information the patients
themselves give us from time to time as to what determined their
inactivity. It is really surprising how frequently something can be
gained either from careful notes taken during the stupor or from the
retrospective accounts of the psychotic experiences. Of course when one
considers the degree of amnesia which is usually present and the extent
of the intellectual defect in general, it becomes obvious that one
cannot think of getting anything like a complete explanation of the
behavior of any given case. Nevertheless this material is quite
suggestive in the mass; it gives one some idea of the mental state as a
whole.
Among 40 cases, 27 offered some explanation either during or following
the psychosis. Of these, 20 spoke of feeling dead, numb or drugged, or
feeling as if paralyzed or having lockjaw. This group, just half of all
the cases, apparently ascribed their disability to something which
seemed physical. One might call them somatopsychic cases. The other 7
gave more allopsychic explanations: 3 attributed their inactivity to
outside influence; 3 more said they were afraid (one of these because
she imagined herself to be in prison), which is analogous to the outside
influence; the 7th case thought she would injure people if she moved.
The following are some examples of the statements of the somatopsychic
group: Laura A.: “I can’t move,” and retrospectively, “My arms were
stiff.” Bridget B. claimed retrospectively that she felt dead or
drugged, that her limbs were lifeless, she felt as if she had lockjaw.
Johanna B. remembered being pricked with a pin on several occasions but
claimed that she did not feel the pain at any time. This suggests a
definitely hysterical mechanism. Anna L. (Case 16) said retrospectively
that she felt as if she were dead, although walking around, and also
that she thought she was a ghost and not supposed to speak. Anna M. said
she had tried to speak but everything stuck in her throat. Alice R. said
that she had no energy, did not want to talk. Meta S. (Case 15) claimed
that while stuporous her tongue would not move. Isabella M. in
intervals claimed that during the stuporous periods she felt as if dead
and said retrospectively when the whole psychosis was over that it was
“an effort to speak.” Johanna S. (Case 13), while stuporous when pressed
with questions would say: “I can’t think,” “I don’t know,” “I am
twisted.” When food was offered her she protested, “I am dead.”
Charlotte W. (Case 12), in reviewing her case, said: “I was mesmerized,”
“I thought I was dead.” Anna G. (Case 1), in retrospect said: “I don’t
think I could speak,” again “I made no effort,” or “I did not care to
speak.” Henrietta H. (Case 8) said, “I lost speech.” She claimed that
she did not move because she was tired and had a numb feeling. Mary C.
(Case 7) said that her tongue had been thick and that she felt dull.
Rose Sch. (Case 6) said during the psychosis that her head was upside
down and retrospectively that she had been mixed up, could not remember
well, did not feel like talking. Mary D. (Case 4) said that she had been
dazed, that she had not felt like talking, and that her limbs “were
stiff like.” We should probably also include here as a delusion of death
the statement of Annie K. (Case 5) who wanted to die and thought she
would do so if she kept still enough.
It is rather striking that among all the forty cases only one spoke of
being sick--“I am so sick.” Only one evaded questions with “that was my
illness.” One would expect a priori that these patients would offer some
vague explanations or make complaints of weakness. If these stupors
were purely physical in origin, one would expect such explanations as
weakness or illness to be offered in accounting for the inactivity. That
there is a rather definite type of explanation offered is, we think,
distinctly suggestive. If one tries to correlate and group the death
ideas, one sees that they are all delusions of death or of loss of
energy or complaints of hysterical symptoms that look like sham death.
If the lack of energy complained of be looked upon as lifelessness, one
can conceive of these explanations being variations of one theme,
namely, that of death. In the last chapter it has been shown that a
delusion of dying, being dead, or having been dead is extremely frequent
in the stupor group. It would seem only natural then to regard the
inactivity, in so far as it may be specifically determined, as an
expression of some such delusion.
Psychiatrists are more or less aware of there being typical ideational
contents in the different manic-depressive psychoses. For instance,
every one is familiar with ideas of wickedness and inadequacy in
depression, ideas of violence in anxiety, or expansive and erotic
fancies in manic states. Quite similarly we have seen that death is a
dominant topic in a stupor. Now in addition to these typical ideas we
often hear expressed what we might term non-specific delusions, ideas
that seem to have nothing to do with a peculiar type of reaction which
the patient presents. It is therefore not surprising to find that
inactivity is not consistently ascribed to death or a related delusion.
For instance, Henrietta B. had much talk of higher powers that were
controlling her, also said that it was fear which kept her quiet.
Josephine G. said retrospectively that she had thought she would injure
people if she moved and that if she opened her eyes she would murder the
people around her. Johanna B. was afraid to talk because she fancied she
was in prison. Laura A.: During her stupor was more vague, saying, “I
can’t move, they won’t let me be,” without betraying any suggestion of
whom “they” might be. Finally Mary C. (Case 7) was still more
indefinite, ascribing her immobility merely to fear. When one considers,
however, that these five were the only ones who gave any atypical
explanation of their inactivity among the thirty-seven cases, the
preponderance of the death idea becomes striking.
2. NEGATIVISM. The next of the cardinal symptoms to be considered is
negativism. This term, which is often loosely used, we would define as
perversity of behavior which seems to express antagonism to the
environment or to the wishes of those about the patient. Naturally it is
only in the minor stupors that we see it in well-developed form as
active opposition and cantankerousness. For example, Harriett C., who
stood about until her feet became edematous, would spit out food when it
was placed in her mouth but would eat if she were left alone with the
food. Josephine G., in a milder state, would turn her back on people.
When more inactive once rolled out of bed and lay on the floor. At this
time also she tried to keep people out of her room. Rarely, patients may
have angry outbursts, as did Annie K. (Case 5) who would strike at the
nurses.
Very often the failure to swallow and anomalous habits of excretion seem
to be negativistic in their nature. One thinks at once of the necessity
for tube-feeding, which is so common even when patients seem otherwise
fairly active. Naturally this form of treatment is necessary only when
the patient refuses to swallow. Quite frequently a refusal to urinate is
met with so that catheterization is necessary, or a patient may never
use the toilet when led to it, but will defecate or urinate so soon as
he leaves it. These latter, like some other perversities, suggest
reactions of a petulant, spoiled child.
By far the commonest manifestation is muscular resistiveness, often
spoken of as “resistiveness.” It was present in thirty-two out of
thirty-seven of our cases. Usually it takes the form of a contraction of
the whole system of voluntary muscles when the patient is touched or the
bed approached. Often it appears only when any passive movement of the
limb is attempted. All muscles of the limb then stiffen, making the
member rigid. Sometimes the negativism is expressed by quite isolated
symptoms, such as stiffness in the jaw muscles alone. One patient showed
no opposition except by holding her urine for two days. Another kept her
eyes constantly directed to the floor. The reaction of another showed
no irregularity except for stiffness in the neck and arms and wetting
herself once after she had been taken to the toilet. One displayed
merely a slight stiffness in her arms. An interesting case was that of
Annie G. (Case 1) who kept one leg sticking out of bed. If this were
pushed in, she would protrude the other. Mary F. (Case 3) sometimes
expressed her antagonism to the environment by slapping other patients.
She spoke only twice in a year and a half, and each time it was when
interfered with. By far the commonest cause of muscular movement in
these inactive cases is resistiveness, and as a rule the inactivity is
interrupted only by negativistic symptoms.
If we look for some explanation or correlation of these symptoms, we
find that chance references to conduct seem to point in the same
direction, namely, to the desire to be left alone. This resentment
against interference again reminds us of the reactions of a spoiled
child. For instance, Laura A., in manic spells during which she was
still constrained and drooled, said, “I don’t want to have my face
washed.” In the intervals she showed an intense muscular resistiveness.
Mary G. used to say, “Leave me alone,” and covered her head or buried it
in the pillows. Maggie H. (Case 14) said in retrospect that she had
wanted to be left alone. Similarly Alice R. thought she did not want to
talk. Emma K. thought that she was in prison and apparently resented
this. Henrietta B. combined in her behavior tendencies both to
compliance and opposition. When her arms were raised they retained the
new position for a minute. Then she dropped them and said, “Stop
mesmerizing me.” But then she put them up again of her own accord, and
when she had done this presented intense resistiveness to any movement.
Later she extended her arms in front of her and said, “I am all right,”
in a theatrical manner, and then added, “Why don’t you go away?”
There seems to be some correlation between inaccessibility and muscular
resistiveness. For example, Charlotte W. (Case 12), whose condition
varied a great deal, always lost the resistiveness when she became
accessible, during which periods she also showed some facial expression.
The resistiveness would invariably return when the inaccessibility
reappeared. Caroline DeS. (Case 2) lost her resistiveness as she became
more accessible, although the inactivity and apathy persisted. This
tendency, which is quite common, suggests that muscular resistiveness
represents a lower level of expression of opposition which patients put
into words or purposeful actions when there is other evidence of some
contact with the environment. Sometimes one observes both general
resistiveness and specific acts. For instance, Mary G., who said, “Leave
me alone,” and covered her head or buried it in the pillows, accompanied
her muscular resistiveness with laughter. This shows the affective
nature of the apparently purposeless muscular tension. The case of Annie
K. (Case 5) is more instructive. In the stage of deeper stupor she had
the automatic type of resistiveness but also outbursts of anger,
particularly toward the nurses, striking one of them she said, “You are
the cause of it all.” When food was offered her, she said, “I wonder
people would not leave me alone sometimes.” Again, when her bed was
approached, she would clutch and hold the bed clothes in an apparently
aimless way as if the impulse to resist never reached its goal.
Retrospectively she could not account for her muscular rigidity on the
basis of definite ideas, and could recall only that she felt stubborn.
In a later period when more accessible, she felt cross and did not want
to be bothered. This emotional attitude was quite conscious with her,
whereas the acts and speech of the earlier period, when her stupor was
more profound, seemed more automatic and impulsive. In other words, the
resistiveness looks like a larval attempt to express an idea which is
probably not fully conscious and therefore gives the appearance of being
aimless. As another example of this we may cite the case of Pearl F.
(Case 9), who said when she recovered, “I was stubborn.” In addition to
the muscular resistiveness she had shown, she would often bite the bed
clothes or scratch herself when she was approached. Mary F. (Case 3),
while in a stupor, slapped at nearby patients quite aimlessly. When
somewhat better, this conduct appeared in a more conscious form, as
sullenness, indifference and smearing of feces (again the behavior of a
naughty child). Here one might quote Laura A. once more, whose
resistiveness when stuporous was intense but who in her manic spells
expressed her negativism in a definite idea, “I don’t want my face
washed.”
To summarize, then, we may say that negativism is apparently the result
of a desire to be left alone, and that muscular resistiveness is a
larval exhibition of the same tendency. But the appearance of this
attitude in such aimless, impulsive acts or habits reminds us strongly
of the dissociation of affect, which was commented on in the previous
chapter. It would seem to be another example of this rather fundamental
tendency of the stupor reaction, not merely to diminish conative
reactions in general, but to reduce their appearance to that of
isolated, partial and therefore rather meaningless expression.
3. CATALEPSY. The last of the cardinal symptoms to be considered is
catalepsy. It occurred in thirteen of thirty-seven cases, although it
was present only as a tendency in three of these. If we define it as the
maintenance of position in which a part of the body is placed regardless
of comfort, we can see that sometimes it is difficult to differentiate
from the phenomenon of resistiveness with its rigidity. It is most
frequently observed in the hands and arms, perhaps because it is, as a
rule, most convenient to demonstrate the retention of awkward positions
in the upward extremities. But any part or even the whole body may be
involved; for example, Charles O. retained standing positions even where
balance was difficult. This phenomenon is often accompanied by “waxy
flexibility,” where the joints move stiffly but retain whatever bend is
given them, like a doll with stiff joints.
The significance of catalepsy is best studied by considering its
relationship to other symptoms and by noting remarks made by the
patients in reference to it. The most important observations which we
have made seem to indicate that it never occurs with that degree of deep
inactivity which suggests a complete lack of mentation on the part of
the patient. One is therefore forced to conclude that back of this
phenomenon there must be some purpose, some kind of an ideational
content, although this may be of a primitive order. This is demonstrably
true in some cases, at least such as that of Isabella M., who left her
arm sticking up in the air but took it down to scratch herself and then
put it back. Somewhat similarly, Charlotte W. (Case 12), when she was
shown during convalescence a photograph of herself in a cataleptic
state, said that that was when she was waiting to go to Heaven and was
afraid to move. Again she remarked, “I was mesmerized.” Josephine G.,
who showed only a tendency to catalepsy, said that she feared the devil
would get control of those about her if she moved. Sometimes there is a
development of this symptom from others which seem to be ideational in
their origin. For instance, Charles O. began making flail-like
movements. These passed over into slow circular motions which finally
subsided into the maintenance of fixed position.
References to hypnotism are not infrequent, and in many cases there is
evidence of a delusion that the posture is desired by those in charge of
the patient. Annie G. (Case 1) said so directly. In retrospect she
explained the holding of her arms in the air by saying, “I thought you
wanted me to have them up.” Henrietta B. at one examination kept her
arms raised in the position in which they had been put for a minute and
then dropped them, saying, “Stop mesmerizing me.” But she then put them
up again of her own accord and now presented intense resistance to any
motion. Later she extended her arms in front of her and said, “I am all
right,” in a theatrical manner. Some patients give evidence in other
symptoms of larval efforts at coöperation with the actual or supposed
wishes of the physician and in such cases it is not impossible that
passive movements are interpreted as orders. One must remember in this
connection that the more primitive are the mental operations of any
individual, the more important do signs, rather than speech, come to be
a medium of communication with other people. As an example of this type
we might mention Rose Sch. (Case 6), who flinched from pin pricks
(showing that she felt them) but made no effort to get away. When
somewhat clearer she said that she was “here to be cured.” Similarly
Mary D. (Case 4), who showed no catalepsy from ordinary tests, kept her
head off the pillow for a long time after it was raised to have her hair
dressed. She showed such perseveration in many constrained positions.
She too flinched from pin pricks but not only made no effort to prevent
them but would even stick out her tongue to have a pin stuck in it.
The relationship of catalepsy to resistiveness is interesting but
unfortunately complicated and unclear. In only one of our cases was
catalepsy definitely present without resistiveness, and in one other a
“tendency to catalepsy” was noted without muscular rigidity being
observed. In this latter case, when the catalepsy became unquestionable,
resistiveness also appeared. It is one thing to note this coexistence
and another to explain it adequately. All that we can offer are mere
speculations as to the real meaning of the association of these
phenomena. It may be that the tension of muscles that occurs when
resistiveness is present gives the idea to the patient of holding the
position. There would be two possible explanations for this. We might
think there is a dissociation of consciousness, like that of hysteria,
where the feeling of tenseness in the muscles that comes from the
resistance to gravity is not discriminated from the resistance to the
movements made by the examiner. On the other hand, there might be a
similar dissociation where the perception of contraction in the
antagonistic muscles is interpreted as the action of the examiner in
placing the limb in a given position. This latter view would seem, on
the face of it, ridiculous, inasmuch as its presumes the existence of
two directly opposed tendencies, namely, those of opposition to the will
of the physician and compliance with it. But ambivalent tendencies are
frequently present in psychopathic states, and moreover we find
occasionally some evidence in the behavior of the patient to
substantiate this view. For example, at one stage of the stupor of Annie
G. (Case 1), her arm could be moved without resistance. Then the elbow
would catch and at this moment the position would be maintained. Such
observation is highly suggestive of the resistance being signal for the
catalepsy. In Isabella M. the catalepsy appeared when resistance to
passive movements also developed. On the other hand, when the resistance
became extreme, the catalepsy was reduced, and vice versa. This makes
one think of two tendencies: suggestibility on the one hand, and
opposition on the other. We might presume that when both are present and
equally strong, stiffness with passive movements results as a kind of
compromise, but when there is a greater development of one, the other is
inhibited.
Such speculations remind one strongly of the psychology of conversion
hysteria and of hypnotism. In some cases of stupor hysterical symptoms
are quite definitely present. For instance, Celia G. began her psychosis
with hysterical convulsions which would terminate with short periods of
stupor. Later the stupor became persistent and during this stage she had
catalepsy (and restiveness as well) in her left arm only. On recovery
from her stupor she complained of stiffness in her hands, which
examination proved to be a purely hysterical difficulty.
This whole subject is without question obscure and many more and very
careful observations are needed before really satisfactory explanations
can be given for these phenomena. That it is a reaction which is related
to the primitiveness of the mental content and the intellectual deficit
in stupor would seem to be a reasonable view, inasmuch as quite similar
phenomena have been observed in a large number of animals, even among
crustaceans. As a result of our own observations the only thing we feel
at liberty to state with real confidence is that catalepsy is presumably
a phenomenon mental in origin rather than somatic, because it always
occurs in conditions which show other evidence of mentation.
Whatever may be the origin of the idea of the posture assumed, there can
be little doubt that its indefinite maintenance is a phenomenon of
perseveration. The conception of the position being in the patient’s
mind, it is easier to hold it than elaborate another idea. This, of
course, is part of the intellectual disorder in stupor. In fact, it is
difficult to imagine any one whose critical faculty was functioning
coöperating in a test for catalepsy.