DIAGNOSIS OF STUPOR
In any functional psychosis an offhand diagnosis is dangerous. When one
deals with such a condition as stupor, however, the problem is exacting,
for, although “stupor” may be seen at a glance, what is seen is really
only a symptom or a few symptoms. “Stupor,” then, is more of a
descriptive than a diagnostic term. The real problem is to determine the
psychiatric group into which the case should be placed. This is a
difficult task, for the differential diagnosis rests on the observation
and utilization of minute and unobtrusive details. A correct
interpretation can be only reached by obtaining a complete history of
the onset and observing the behavior and speech of the patient for a
long period, usually of weeks, sometimes of months. With these
precautionary words in mind, it may be well to summarize briefly the
diagnostic problems in connection with benign stupor.
In the first place one naturally considers the differentiation from
conditions of organic stupor or coma. Since psychotic stupors never
develop without some signs of mental abnormality, the history is usually
a sufficient basis for final judgment. In case no anamnesis is
obtainable the functional nature of the trouble may be recognized by the
absence of those physical signs which characterize the organic stupors.
One sees no violent changes in respiration, pulse or blood-pressure,
such as are present in the intoxication comas of diabetes or nephritis.
There is no characteristic odor to the breath, and the urine is
relatively normal. The unconsciousness of trauma or apoplexy is
accompanied by focal neurological signs. Even in aerial concussion (so
frequently seen in the war) where no one part of the brain is
demonstrably affected more than another, there are neurological
evidences of what one might call “physiological” unconsciousness. The
eyes roll independently, the pupils fail to react to light. On the other
hand, there are definite symptoms characteristic of the functional
state. Mental activity is evidenced by a muscular resistiveness or
retention of urine. Even in states of complete relaxation the eyes move
in unison, the pupils react to light, and almost universally the corneal
reflex is present. The patient appears in a deep sleep rather than
actually unconscious.
The post-epileptic sleep may resemble a stupor strongly. But this
condition is temporary and the situation and appearance of the patient
betrays the fact that he has just had a convulsion. Rarely, protracted
stuporous states occur in epilepsy which closely resemble the conditions
described in this book. In fact it is probable the true stupors may
occur in epilepsy just as in dementia præcox or manic-depressive
insanity.
There is usually little difficulty in the discrimination of hysterical
stupor. Occasionally it shows, superficially, a similarity to the
manic-depressive type. Fundamentally, there is a wide divergence between
the two processes, in that in the hysterical form a dissociation of
consciousness takes place, the patient living in a reminiscent,
imaginary or artificially suggested environment, while in a true stupor
there is a withdrawal of interest as a whole and a consequent diffuse
reduction of all mental processes. This difference is sooner or later
manifested by the appearance in the hysteric of conduct or speech
embodying definite and elaborated ideas.
As has been stated fully in the last chapter (to which the reader is
referred), the stupor of dementia præcox is to be differentiated from
that of manic-depressive insanity by the inconsistency of the symptoms
in the former and the appearance of dementia præcox features during the
stupor, such as inappropriate affect, giggling, or scattering. Further,
the nature of the disorder is usually manifest before the onset of the
stupor as such.
Sometimes very puzzling cases occur in more advanced years when it is
difficult to say whether one is dealing with involution melancholia or
stupor. Such patients show inactivity, considerable apathy and wetting
and soiling, and with these a whining hypochondria, negativism, and
often a rather mawkish sentimental death content without the dramatic
anxiety which usually characterizes the involution state. In these cases
the diagnosis is bound to be a matter of taste. In our opinion it is
probably better to regard these as clinically impure types. They may be
looked on as, fundamentally, involution melancholias (the course of the
disease is protracted, if not chronic) in whom the regressive process
characteristic of stupor is present as well as that of involution.
Great difficulties are also met with in the manic-depressive group
proper. So often a stupor begins with the same indefinite kind of upset
as does another psychosis that the development may furnish no clew. Any
condition where there is inactivity, scanty verbal productivity and poor
intellectual performance resembles stupor. This triad of symptoms occurs
in retarded depressions, in absorbed manic states and in perplexities.
Negativism and catalepsy are never well developed except in stupor. So
if these symptoms be present the diagnosis is simplified. But they are
often absent from a typical stupor. Let us consider these three groups
separately.
The most important difference between stupor and depression lies in the
affect. Although inactive and sometimes appearing dull the depressive
individual is not apathetic but is suffering acutely. He feels himself
wicked, paralyzed by hopelessness, and finds proof of his damnation in
the apparent change of the world to his eyes and in the slowness of his
mind. But he is acutely aware of these torments. The stupor patient, on
the other hand, does not care. He is neither sad nor happy nor anxious.
This contrast is revealed not only by the patients’ utterances but by
their expressions. The stuporous face is empty, that of the other lined
with melancholy. The intellectual defect, too, is different. In retarded
depression the patient is morbidly aware of difficulty and slowness, but
on urging often performs tests surprisingly well. In the stupor,
however, one is faced with an unquestionable defect, a sheer
intellectual incapacity.
In Chapter VIII the differential diagnosis between perplexity and stupor
has already been touched upon. Here again the affect is a point of
contrast. The patient has not too little emotion but too much. The
feeling of intangible, puzzling ideas and of an insecure environment
causes the subject distress, of which complaint is made and which can be
witnessed in the furrowed brow and constrained expression. There is
also, as we have seen, a rich ideational content in these cases, if one
can get at it. The mind is not a blank, as in the stupor, or concerned
only with delusions of death.
Finally, there are the absorbed manic states. These are the most
difficult, inasmuch as the patient is often so withdrawn and so
introverted that at any given interview there may be no objective
evidence of mood or ideas. Here the development of the psychosis is
often an aid to diagnosis. The patient passes through phases of
hypomania to great exultation, the flight becomes less intelligible,
with this the activity diminishes until finally expression in any form
disappears. If this sequence has not been observed, continued
observation tells the tale. The patient still has his ideas and may be
seen smiling contentedly over them (not vacuously as does the
schizophrenic) or he may break into some prank or begin to sing. Any
protracted familiarity with the case leads to a conviction that the
patient’s mind is not a blank, but that his attention is merely directed
exclusively inward. Then, too, when his ideas are discovered, it is
found that they are not exclusively occupied with the topic of death.