PSYCHOLOGICAL EXPLANATION OF THE STUPOR REACTION
In the previous chapter mention has been made of our view that
manic-depressive insanity is a disease fundamentally based on some
constitutional defect, presumably physical, but that its symptoms are
determined by psychological mechanisms. In accordance with this
hypothesis we seek, when studying the different forms of insanity
presented in this group, to differentiate between the different types of
mental mechanisms observed, and by this analysis to account for the
manifestations of the disease on purely psychological lines. If benign
stupors belong to this group, then we should be able to find some
specific psychology for this type of reaction.
All speech and all conduct, except simple reflex behavior, are
presumably determined by ideas. When an individual is not aware of the
purpose governing his action, we assume, in psychological study, that an
unconscious motive is present, so that in either case the first step in
psychological understanding of any normal or abnormal condition is to
discover, if possible, what the ideas are that lead to the actions or
utterances observed. In the case of stupors the situation is fairly
simple, in that the ideational content is extremely limited. As has been
seen, it is confined to death and rebirth fancies, other ideas being
correlated with secondary symptoms, such as belong to mechanisms of
other manic-depressive psychoses. It is not necessary to repeat the
catalogue of the typical stupor ideas, as they have been given in an
earlier chapter. Our task is now to consider the significance of these
death and rebirth delusions and their meaning for the stupor reaction.
Thoughts concerned with future and new activities require energy for
their completion in action and are therefore naturally accompanied by a
sense of effort which gives pleasure to an active mind. When the sum of
energy is reduced, one observes a reverse tendency called “regression.”
It is easier to go back over the way we know than to go forward, so the
weakened individual tends to direct his attention to earlier actions or
situations. To meet a new experience one must think logically and keep
his attention on things as they are, rather than imagine things as one
would like to have them.
Progressive thinking is therefore adaptive, while regressive thinking is
fantastic in type, as well as concerned with the past--a past which in
fancy takes on the luster of the Golden Age. Sanity and insanity are,
roughly speaking, states where progressive or regressive thinking rule.
The essence of a functional psychosis is a flight from reality to a
retreat of easeful unreality.
Carried to the extreme, regression leads one in type of thinking and in
ideas back to childhood and earliest infancy. The final goal is a state
of mental vacuity such as probably characterizes the infant at the time
of birth and during the first days of extra-uterine life. In this state
what interest there is, is directed entirely to the physical comfort of
the individual himself, and contact with the environment is so
undeveloped that efforts to obtain from it the primitive wants of warmth
and nutrition are confined to vague instinctive cries. Evolution to true
contact with the world around implies effort, the exercise of
self-control, and also self-sacrifice, since the child soon learns that
some kind of _quid pro quo_ must be given. Viewed from the adult
standpoint, the emptiness of this early mental state must seem like the
Nirvana of death. At least death is the only simple term we can use to
represent such a complete loss of our habitual mental functions. When
life is difficult, we naturally tend to seek death. Were it not for the
powerful instinct of self-preservation, suicide would probably be the
universal mode of solving our problems. As it is, we reach a compromise,
such as that of sleep, in which contact with reality is temporarily
abandoned. In so far as sleep is psychologically determined, it is a
regressive phenomenon. It is interesting that the most frequent
euphemism or metaphor for death is sleep. Sleep is a normal regression.
It does not always give the unstable individual sufficient relaxation
from the demands of adaptation and so pathological regressions take
place, one of which we believe stupor to be. It is important to note
that objectively the resemblance between sleep and stupor is striking.
So far as mental activity in either state can be discovered by the
observer, either the sleeper or the patient in stupor might be dead.
Briefly stated, then, our hypothesis of the psychological determination
of stupor is that the abnormal individual turns to it as a release from
mental anguish, just as the normal human being seeks relief in his bed
from physical and mental fatigue. When this desire for refuge takes the
shape of a formulated idea, there are delusions of death.
The problem of sleep is, of course, bound up with the physiology of
rest, and as recuperation, in a physical sense, necessitates temporary
cessation of function, so in the mental sphere we see that relaxation is
necessary if our mental operations are to be carried on with continued
success. This is probably the teleological meaning of sleep in its
psychological aspects, for in it we abandon diurnal adaptive thinking
and retire to a world of fancy, very often solving our problems by
“sleeping over them.” The innate desire for rest and a fresh start is
almost as fundamental a human craving as is the tendency to seek release
in death. In fact the two are closely associated both in literature and
in daily speech, for in many phases we correlate death with new life. If
one is to visualize or incorporate the conception of new life in one
term, rebirth is the only one which will do it, just as death is the
only word which epitomizes the idea of complete cessation of effort.
Not unnaturally, therefore, we find in the mythology of our race, in our
dreams and in the speech of our insane patients, a frequent correlation
of these two ideas, whether it comes in the crude imagery of physical
rebirth or projected in fantasies of destruction and rebuilding of the
world. Many of our psychotic patients achieve in fancy that for which
the Persian poet yearned:
“Ah Love! could you and I with Him conspire
To grasp this Sorry Scheme of Things entire,
Would we not shatter it to bits--and then
Re-mold it nearer to the Heart’s Desire!”
A vision of a new world is a content occurring not infrequently in manic
states, but before the universe can be remolded it must be destroyed.
Before the individual can enjoy new life, a new birth, he must die, and
stupor often marks this death phase of a dominant rebirth fantasy. In
this connection it was not without significance to note that stupors
almost universally recover by way of attenuation of the stupor symptoms,
or in a hypomanic phase where there seems to be an abnormal supply of
energy. Antæus-like, they rise with fresh vigor from the Earth. They do
not pass into depressions or anxieties.
Rebirth fancies unquestionably, then, contain constructive and
progressive elements, but, as has been stated above, any thinking which
implies a lapse of contact with the environment is, in so far as that
lapse is concerned, regressive, and in consequence rebirth fancies, as
dramatized by the stupor patients, are regressive, just as are the
delusions of death itself.
It is obvious that an acceptance of death implies rather thorough mental
disintegration. Before that takes place there may be some mental
conflict. The instinct of self-preservation may prevent the individual
from welcoming the notion of dissolution, so that this latter idea,
though insistent, is not accepted but reacted to with anxiety; hence we
often meet with onsets of stupor characterized by emotional distress. It
has already been suggested that death may foreshadow another existence.
Often in the psychoses we meet with the idea of eternal union in death
with some loved one whom the vicissitudes and restrictions of this life
prevent from becoming an earthly partner. This fancy is frequently the
basis of elation. Similarly, new life in a religious sense as expressed
in the delusion of translation to Heaven, is a common occasion for
ecstasy. These formulations of the death idea may occur as tentative
solutions of the patient’s problems leading to temporary manic episodes
while the psychosis is incubating. It seems that stupor as such appears
only when death and nullity are accepted.
The above are more or less a priori reasons for regarding the stupor as
a regressive reaction. We must now consider the clinical evidence to
support this view. In the first place, we always find that stupor occurs
in an individual who is unhappy and who has found no other solution
than regression for the predicament in which he is. There is nothing
specific in the cause of this unhappiness. At times the factors
producing it are mainly environmental; at others, the problem is
essentially of the patient’s own making. Of course almost any type of
functional psychosis may emerge from such a state of dissatisfaction,
but it is important to note that unlike manic states, for instance,
stupors invariably develop from a situation of unhappiness. Quite
frequently the choice of the stupor regression is determined by some
definitely environmental event which suggests death. This often comes as
the actual death of the patient’s father (in the case of a woman) or
employer, events which inflate the already existing, although perhaps
unconscious, desire for mutual death. Again, the precipitating factor
may be a situation which adds still another problem and makes the burden
of adaptation intolerable, forcing on him the desire for death. In these
cases the actual psychosis is sometimes ushered in dramatically with a
vision of some dead person (often a woman’s father) who beckons, or
there are dream-like experiences of burial, drowning, and so on.
A few cases taken at random from our material exemplify these features
of the unhappiness in which the psychosis appears as a solution with its
development of the death fancy.
Alice R., at the age of 25, was much troubled by worrying over her
financial difficulties and the shame of an illegitimate child.
Retrospectively she stated, “I was so disgusted I went to bed--I just
gave up hope.” Shortly before admission she said she was lost and
damned, and to the nurse in the Observation Pavilion she pleaded, “Don’t
let me murder myself and the baby.”
Caroline DeS. (Case 2) for some time was worried over the engagement of
her favorite brother to a Protestant (herself a Catholic) and the
threatened change of his religion. At his engagement dinner she had a
sudden excitement, crying out, “I hate her--I love you--papa, don’t kill
me.” This excitement lasted for three weeks, during two of which she was
observed, when she spoke frequently of being killed and going to Heaven.
The conflict was frankly stated in the words, “I love my father but
don’t want to die.” Then for two weeks she had some fever, was tube-fed,
muttered about being killed or showed some elation, there being
apparently interrupted stuporous, manic and, possibly, anxiety episodes.
Finally she settled down to a year of deep stupor.
Laura A. had for three months poor sleep with depression over her
failure in study. Another cause for worry was that her father was home
and out of work. She reached a point where she did not care what
happened but continued working. Ten days before admission she was not
feeling well. The next morning she woke up confused and frightened,
speedily became dazed, stunned, could not bring anything to her memory.
This rather sudden stupor onset was not accompanied by any false ideas,
at least none which the family remembered.
Mary C. (Case 7) was an immigrant who felt lonely in the new country.
Two weeks before admission her uncle with whom she was living died. She
thought she had brought bad luck, complained of weakness and dizziness,
then suddenly felt mixed up, her “memory got bad,” and she thought she
was going to die. Next she was frightened, heard voices, thought there
was shooting and a fire. For a short time she was inactive and later
began shouting “Fire!” When taken to the Observation Pavilion, she was
dazed, uneasy, thought she was on a boat or shut up in a boat which had
gone down; all were drowned. Then came a mild stupor.
Maggie H. (Case 14), while pregnant, fancied that her baby would be
deformed and that she would die in childbirth. Three weeks before
admission this event took place. For five days she worried about not
having enough milk, about her husband losing his job (he did lose it)
and thought her head was getting queer. On the fifth day she cried, said
she was going to die, that there was poison in the food, that her
husband was untrue to her. She became mute but continued to attend to
her baby. She saw dead bodies lying around, and by the time she was
taken to the Observation Pavilion was in a marked stupor.
Turning now to the symptoms of the stupor proper, we note, first, the
effects of the loss of energy which regression implies. The inactivity
and apathy which these patients show is too obviously evidence of this
to require further comment. Another proof of the withdrawal of the
libido or interest is found in the thinking disorder. Directed, accurate
thinking requires effort, as we all know from the experience of our
laborious mistakes when fatigued. So in stupor there is an inability to
perform simple arithmetical problems, poor orientation is observed, and
so on. Similarly what we remember seems to be that which we associate
with the impressions received by an active consciousness. Actual events
persist in memory better than those of fancy, in proof of which one
thinks at once of the vanishing of dreams on waking, with its
reëstablishment of extroverted consciousness. This registration of
impressions requires interest and active attention. Without interest
there is no attention and no registration. The patient in stupor
presents just the memory defect which we would expect. Indifference to
his environment leads to a poor memory of external events, while on
recovery there may be such a divorce between consciousness of normal and
abnormal states that the past delusions are wiped from the record of
conscious memory. Withdrawal of energy then produces not only inactivity
and apathy but grave defects in intellectual capacity.
The natural flow of interest in regression is to earlier types of
ambition and activity. This is betrayed not merely by the thought
content dealing with the youth and childhood of the patient, but also is
manifested in behavior. Excluding involution melancholia there is
probably no psychosis in which the patients exhibit such infantile
reactions as in stupor. Except for the stature and obvious age of these
patients, one could easily imagine that he was dealing with a spoiled
and fractious infant. One thinks at once of the negativism which is so
like that of a perverse child and of the unconventional, personal habits
to which these patients cling so stubbornly. Masturbation, for instance,
is quite frequent, while willful wetting and soiling is still more
common. We sometimes meet with childishness, both in vocabulary and mode
of expression. In one case there was evidently a delusion of a return to
actual childhood, for she kept insisting that she was “in papa’s house.”
The frequency with which the delusion of mutual death occurs in stupor
is another evidence of its regressive psychology. The partner in the
spiritual marriage is rarely, if ever, the natural object of adult
affection, but rather a parent or other relative to whose memory the
patient has unconsciously clung for many years, reawakening in the
psychosis an ambition of childhood for an exclusive possession that
reaches its fulfillment in this delusion. Closely allied with this is
another delusion, that of being actually dead, which the patients
sometimes express in action, even when not in words. The anesthesia to
pin pricks, the immobility and the refusal to recognize the existence of
the world around, in patients who give evidence of some intellectual
operations still persisting, are probably all part of a feigned death,
with the delusion expressing itself in corpse-like behavior.
Finally we must consider the meaning of the deep stupor where no
mentation of any kind can be proven and where none but vegetative
functions seem to be operating. This state is either one of organic
coma, in which case it marks the appearance of a physical factor not
evidenced in the milder stages, or else it is the acme of this
regression by withdrawal of interest. As has been stated, back of the
period of primitive childish ideas there lies a hypothetical state of
mental nothingness. If we accept the principle of regression we find
historically an analogue to what is apparently the mental state of deep
stupor in the earliest phases of infancy. This view receives
justification from the study of the phenomenon of variations in
symptoms. Mental faculties at birth are larval, and if such condition be
artificially produced mental activity must be potentially present (as it
would not be if we were dealing with coma). In Chapter IV phenomena of
interruption of stupor symptoms were detailed. One case that was
mentioned is now of particular importance as demonstrating that an
appropriate stimulus may dispel the vacuity of complete stupor by
raising mental functions to a point where delusions are entertained.
This patient retrospectively recalled only certain periods of her
deepest stupor, occasions when she was visited by her mother. At these
times, as she claimed, she thought she was to be electrocuted and told
her mother so, adding, “Then it would drop out of my mind again.”
Otherwise her memory for this state was a complete blank. Here we see a
normal stimulus producing not normality but something on the way towards
it, that is, a condition less profound than the state out of which the
patient was temporarily lifted.
This case exemplifies the principle of levels in the stupor reaction
which we have found to be of great value in our study. These levels are
correlated with degrees of regression, as a review of the symptoms
discussed above may show. In the first place, the dissatisfaction with
life, the first phase of regression, leads to the quietness--the
inactivity and apathy, which are the most fundamental symptoms of the
stupor reaction as a whole. Initiative is lost and with this comes a
tendency for the acceptance of other people’s ideas. That is the
probable basis for the suggestiveness which we concluded was a prominent
factor in catalepsy. Indifference and stolidity may exist with those
milder degrees of regression which do not conflict with one’s critical
sense, and hence may be present without any false ideas. The next stage
in regression is that where the idea of death appears. Although not
accepted placidly by the subject, its non-acceptance is demonstrated by
the idea being projected--by its appearance as a belief that the patient
will be killed. This notion of death coming from without has again two
phases, one with anxiety where normality is so far retained that the
patient’s instinct of self-preservation produces fear, and a second
phase where this instinct lapses and the patient so far accepts the
idea of being killed as to speak of it with indifference. The next step
in regression is marked by the spoiled-child conduct, interest being so
self-centered as to lead to autoerotic habits and the perverse reactions
which we call negativism. When death is accepted but mental function has
not ceased, the latter is confined to a dramatization of death in
physical symptoms or to such speech and movements as indicate a belief
that the patient is dead, under the water, or in some such unreal
situation. Finally, when all evidence of mentation in any form is
lacking, we see clinically the condition which we know as deep stupor
and which we must regard psychologically as the profoundest regression
known to psychopathology, a condition almost as close to physiological
unconsciousness as that of the epileptic.
Naturally we do not see individual cases in which all these stages
appear successively, each sharply defined from its predecessor. To
expect this would be as reasonable as to look for a man whose behavior
was determined wholly by his most recent experience. Any psychologist
knows that every human being behaves in accordance with influences whose
history is recent or represents the habit of a lifetime. At any given
minute our behavior is not simply determined by the immediate situation,
but is the product of many stages in our development. Quite similarly we
should not expect in the psychoses to find evidences of regression to a
given period of the individual’s life appearing exclusively, but rather
we should look for reactions at any given time being determined
preponderantly by the type of mentation characteristic for a given stage
of his development. As a matter of fact, we see in psychoses,
particularly in stupor, more sharply defined regressions to different
levels than we ever see in normal life.
Our psychological hypothesis would be incomplete and probably unsound if
it could not offer as valid explanations for the atypical features in
our stupor reactions as for the typical. The unusual features which one
meets in the benign stupors are ideas or mood reactions occurring
apparently as interruptions to the settled quietude or in more
protracted mild mood reactions, such as vague distress, depression or
incomplete manic symptoms, which have been described in the chapter on
affect. The interruptions are easily explained by the theory of
regression. If stupor represents a complete return to the state of
nothingness, then the descent to the Nirvana or the re-ascent from it
should be characterized by the type of thinking with the appropriate
mood which belongs to less primitive stages of development. A review of
our material seems to indicate that there is a definite relationship
between the type of onset and the character of the succeeding stupor.
For instance, in the cases so far quoted in this book, the onsets
characterized by mere worry and unhappiness and gradual withdrawal of
interest had all of them typical clinical pictures. On the other hand,
of those who began with reactions of definite excitement, anxiety or
psychotic depression, there were interruptions which looked like
miniature manic-depressive psychoses in all but one case. This would
lead one to think that these patients retraced their steps on recovery
or with every lifting of the stupor process, moved slightly upward on
the same path on which they had traveled in the first regression. The
case of Charlotte W. (Case 12), which is fully discussed in the chapter
on Ideational Content, offers excellent examples of these principles.
The next atypical feature is the phenomenon of reduction or dissociation
of affect, the frequency of which is mentioned in Chapter V. As the law
of stupor is apathy, normal emotions should be reduced to indifference
and no abnormal moods, such as elation, anxiety or depression, should
occur. What often happens is that these psychotic affects appear but
incompletely, often in dissociated manifestations. This looks like a
combination of two psychotic tendencies, the stupor reduction process
which inhibits emotional response and the tendency to develop abnormal
affects which characterize other manic-depressive psychoses. There is no
general psychological law which makes this view unlikely. One cannot be
anxious and happy at the same instant, although one can alternate in his
feelings; but one can fail to react adequately to a given stimulus when
inhibited by general indifference. In fact it is because apathy is,
properly speaking, not a mood but an absence of it, that it can be
combined with a true affect. It is possible, therefore, to have a
combination of stupor and another manic-depressive reaction, while the
others cannot combine but only alternate.[11]
Finally we must discuss the psychological meaning of cases, such as
those described in Chapter VIII, where we concluded that there were
psychoses resembling stupors superficially. It seemed likely that these
patients were absorbed in their own thoughts, rather than being in a
condition of mental vacuity. It is not difficult to explain the
objective resemblance. All evidence of emotion (apart from subjective
feeling tone which the subject may or may not report) is an expression
of contact with the outer world. There must be externalization of
attention to environment before a mood becomes evident. A moment’s
reflection will show this to be true, for no further proof is needed
than the phenomena of dreaming. The attention being given wholly to
fantasies, the subject lies motionless, mute and placid, although
passing through varied autistic experiences. Only when the dream becomes
too vivid, disturbs sleep and re-directs attention to the
environment--only then is emotion objectively betrayed. There is an
appearance of apathy and mental vacuity which the dreamer can soon
declare to be false. He was feeling and thinking intensely. In any
condition, therefore, such as that of perplexity or of an absorbed manic
state, the patient may be objectively in the same condition as a typical
stupor. The histories of the two psychoses differentiate the two
reactions which may be indistinguishable at one interview. The keynote
of one reaction is _indifference_, while that of absorption is
_distraction_, a perversion of attention to an inner, unreal world.
In summary we may recapitulate our hypotheses. Stupor represents,
psychologically speaking, the simplest and completest regression.
Adaptation to the actual environment being abandoned, attention reverts
to earlier interests, giving symptoms of other manic-depressive
reactions in the onset or interruptions, and finally dwindles to
complete indifference. The disappearance of affective impulse leads to
objective apathy and inactivity, while the intellectual functions fail
for lack of emotional power to keep them going. The complicated mental
machine lies idle for lack of steam or electricity. The typical
ideational content and many of the symptoms of stupor are to be
explained as expressions of death, for a regression to a Nirvana-like
state can be most easily formulated in such a delusion. Other clinical
conditions may temporarily and superficially resemble stupor on account
of the attention being misdirected and applied to unproductive
imaginations. To employ our metaphor again, in these false stupors the
current is switched to another, invisible machine but not cut off as in
true stupor.
FOOTNOTES:
[11] The reader will note that this view is opposed to that of
Kraepelin, who has written largely on so-called “_mixed conditions_” in
manic-depressive insanity. We believe that careful clinical studies
confirm our opinion and that his classification is based on less
thorough observation and analysis. This subject will be discussed at
greater length in a forthcoming book on “The Psychology of Morbid and
Normal Emotions,” by Dr. MacCurdy.