Emil Kraepelin.

Clinical psychiatry: online

. (page 21 of 45)
Online LibraryEmil KraepelinClinical psychiatry: → online text (page 21 of 45)
Font size
QR-code for this ebook

been removed, their throats occluded, and the blood no longer
cu-culates. They are transformed mto stones, their coun-
tenances are completely altered, they cannot talk, eat, or
walk Uke other men, etc.

HaUiudnaMons, especially of hearing, are very prominent
during this stage; fellow-men jeer at them, call them bas-
tards, threaten them, accuse them of horrible crimes, and
numerous slanderous telephone messages are overheard.
Occasionally faces and forms are seen at night, or a crowd
of men throwing stones at the window. Foul vapors may
be thrown into their bedding.

The patients show agitation; they are anxious, restless,
quarrelsome, and emotional. They laugh, cry, and sing.
The orientation is not disturbed. In conduct, they may
perform all kinds of serious and outlandish acts, attempting
suicide, assaulting persons, and committing arson.

The emotional attitude soon changes and becomes more
and more exalted. At the same time the delusions become
less depressive and more expansive and fantastic. The
patient in spite of persecution is happy and contented, ex-
travagant and talkative, and boasts that he has been trans-
formed into the Christ; others will ascend to heaven, have
Uved many Uves, and traversed the universe. They have
the talent of poets, have been nominated for President,
and have represented the government at foreign courts.
These delusions may become most florid, foolish, and ridicu-
lous. A patient may say that he is a star, that all light and
darkness emanate from him; that he is the greatest in-
ventor ever bom, can create mountains, is endowed with
all the attributes of God, can prophesy for coming ages, can
talk to the people in Mars; indeed, is unlike anything that
has ever existed.

Associated with these variegated and ever changing ex-

Digitized byVjOOQlC


pansive delusions there are delusions of persecution almost
as absurd and extreme, but expressed without correspond-
ing emotion. Patients smilingly complain that they have
been deprived of their hmbs, have been pierced with thou-
sands of bullets, and been thrown into hell, where they were
exposed to furnace flames. Suggestions for many of these
delusions may be obtained from pictures on the wall or from
reading. The hallucinations also become more extreme.
Angels descend from heaven and commune with them daily,
God also talks to them, the President directs their conduct,
beautiful visions are displayed at night which are full of

These patients are usually talkative and express freely
their many delusions. Some of them fill hundreds of sheets
of paper tiying to describe them. At first they are quite
coherent, but later there is such a wealth of ideas loosely
expressed that it is difficult to follow them. They wander
aimlessly about from one delusion to another, and show
frequent repetitions of the same ideas. Questions, however,
are answered in a coherent and relevant manner. Later
in the course of the disease the speech becomes more and
more difficult of comprehension, because of the number
of peculiar phrases and neologisms to which they attach
special significance and freely repeat. The writings like-
wise become more and more xmintelligible.

The patients rarely possess insight into their condition.
The conscumsneas usually becomes somewhat clouded, es-
pecially later in the disease. Orientation as to place is
least disturbed, but people are soon mistaken and often
designated as celebrated personages, and all conception of
time is lost. Patients recognize relatives and can give a fairly
clear statement as to where they are. They may recall
some past knowledge, but they soon become unable to use

Digitized byVjOOQlC


it in reasoning and utterly fail to follow long conversations.
They cannot apply themselves to any mental work. The
patients show an exaltation of the ^o with heightened
feelings, they are self-conscious, with an important manner,
and demand special attention. In emotionol attitude they
are almost alwajrs exalted, rarely depressed, although a few
patients show restlessness, some irritabihty, and occasionally
some passion, often in connection with the menses. In-
creased sexual excitement is also common. Some patients
are able to do some mechanical work, but need supervision
because of their capriciousness and fickleness.

Physical Symptoms. — There is very little physical dis-
turbance except the loss of weight and insomnia at the on-
set, faulty nutrition, and occasionally increased vasomotor
irritabihty with easy blushing and blanching.

Course. — The course is progressive without remissions.
The signs of mental deterioration may appear within a few
months, and are usually well marked by the end of two years.

The patients may for a long time retain clear conscious-
ness and partial orientation, but the content of thought
becomes thoroughly incoherent and there is a lack of energy
and plan in their activity, which incapacitates them for all
mental appUcation. While active and somewhat interested
in their environment, they still display a self-conscious
serenity. From this stage of dementia there may be no
further progress for a number of years. Occasionally tran-
sitory exacerbations of excitement or depression occur.
Finally there may be periods when the patients disclaim
their delusions and refer to them as foolishness, but at the
same time they do not r^ain clear insight.

Second Group. — There is provisionally grouped here a
larger series of cases which are characterized by fantastic
ddvmana uaually accompanied by numerous hallvcinations

Digitized byVjOOQlC


which are more coherently developed and expressed for a num-
ber of years, when they either become incomprehensible or dis-
appear altogether, leaving the patients in a condition of mod-
erate dem^entia.

Symptomatology. — The first symptoms to appear are
those of despondency with some self-accusation. The pa-
tients are troubled with thoughts of death and religious
doubts; they are unusually devout, and seek rehgious ad-
vice. They fear that they have done wrong, have committed
some crime, or are suffering the penalty of self-abuse. C5o-
herent delusions of persecution develop gradually; people
watch them, pecuUar actions are noticed, acquaintances
are less friendly, and children on the street jeer and laugh
at them, perhaps mimicking their manners. Strangers on
the street turn and stare. In pubUc places, in the cars, and
at the church, they observe pecuhar acts which refer to them.
They beUeve themselves hbelled by the newspapers. They
imderstand these mysterious occurrences and will shortly
expose the offenders and bring them to justice. Affairs at
home are unsatisfactory; the children are different, and the
husband or wife is imfaithful.

Hallucinations, especially of hearing, rarely of sight, are
prominent at this time, aiding in the elaboration of the
delusions. Enemies take advantage of their confinement
by standing below the window, calling them all sorts of names,
announcing that they are to be imprisoned, that they have
committed murder, and are to be put to the rack. Voices
are heard from the walls and from under the floor, stating
that they are wretches and outcasts of society. Very often
the noises really heard, such as the blowing of whistles and
the ringing of bells, are misinterpreted in accord with their
delusions. They complain that the food contains poison
which they can taste, they suspect phosphorus in the tea

Digitized byVjOOQlC


and detect kerosene on the clothing. They notice that
their clothing is changed, buttons are missing, there is a
rip in the coat and a pocket torn. Objects in their surround-
ings are changed in order to confuse them.

Delusions of physical influence become particularly promi-
nent. Many common somatic sensations, such as twitch-
ing of individual muscles, headache, specks before the eyes,
pain about the heart, and cramp in the bowels are all evi-
dences of such influences wielded by their enemies. The
explanations of these somatic sensations are often most
fantastic. An itching of the foot is sufficient evidence
that a poisonous powder has been blown into their shoes,
pain in the back indicates that they have been s]iot there
while asleep, a frontal headache is the result of poisonous
vapors, which are set free in the room at night in order to
destroy their intellect. A tremor of the fingers is pro-
duced by means of electric currents sent through the
air. Something is placed in their food to create sexual

Their persecutors employ the most varied means in pro-
ducing physical discomfort. All known agencies are men-
tioned, as, magnetism, hypnotism. X-rays, telepathy, and
electricity. Organs of the body are removed and then re-
placed out of order, and the intestines are shrunken. It is
quite characteristic for the patients to refer to these physi-
cal changes by some invented names, such as, ugly duberty,
snicking, lobster cracking, etc. Others complain that their
minds are influenced, their thoughts are gone, they have
no control over their thoughts, which, in spite of themselves,
are always evil. They attribute the origin of such thoughts
to others. Frequently they complain of " drawing of the
thoughts," and they may say that they don't know whether
their thoughts are their own or suggested by some one else.

Digitized byVjOOQlC


Sometimes their thoughts become audible (double thought),
especially when reading. Their thoughts are known to the
whole world.

Ideas of spirit-possession are often a prominent feature.
Here the enemy enters and takes possession of the body,
causing the bones to crack and the head to rattle; obscene
remarks proceed from the stomach; their ears are filled by
all sorts of noises made by these spirit-possessors. They
cause the testicles to fall and the throat to dry up.

In connection with the delusions of influence there de-
velops in almost all cases more and more pronounced expan-
sive delusions. These are as vari^ated and fantastic as
those of persecution. The patients have been awarded a
prize for bravery and now rule the country, possess beautiful
dresses, and are betrothed to the king, etc. God daily
appears to them and gives them a blessing. They have
recently been intrusted with millions which they are to in-
vest in mining. They have consununated an immense
trust, of which they are president. All of the many delusions
expressed by the patients are at first coherent, and may be
partially systematized; but in the course of a few years, they
tend to become somewhat incoherent, and at the same time
the hallucinations become more agreeable.

The conscumsness during the development of these de-
lusions, and for a long time afterward, perhaps years, re-
mains clear, and the patients are oriented. Thought is
coherent, but centers about the delusions. The patients are
able at first to offer some basis for the delusions, to refute
objections, and to show some " method " in their ideas;
but later, as deterioration appears gradually in the course of
several years, thought becomes confused, and the delusions
incoherent, contradictory, and changeable. There is rarely
insight into the disease. Many patients appreciate that they

Digitized byVjOOQlC


are not normal, but their defects and ailments are rather
regarded as the work of their persecutors.

The emotional attitude is at first one of depression, with
anxiety and combativeness, but later this gives way to a
certain amount of happiness and cheerfulness, with con-
siderable ^oism. There may be transitory outbreaks of
anxiety as well as of irritabihty. In some cases stuporous
states have been observed.

The conduct is mostly in accord with the delusions; the
patients are suspicious, journeying about to get rid of their
enemies, applying to police for protection; or, taking the
matter in their own hands, they attack supposed persecutors
or attempt to expose them through the papers. Others for
self-protection contrive a sort of armor for themselves, place
metals in their shoes or wires in their clothing to divert the
electrical currents, etc. In accord with expansive delusions
they may decorate themselves in fantastic costumes, adorn
themselves with badges, assume a superior air, and use high-
flown language.

Furthermore, during the course of the disease peculiarities
of conduct develop, such as, grimacing, striking gesticu-
lations, mannerisms in eating, walking, and speaking, as
well as signs of negativism or of stereotypy.

Course. — The duration of the disease extends through
many years. It is sometimes possible to discern certain
stages in its development: at first a change of disposition,
then a prominence of delusions of persecution, later the
appearance of delusions of grandeur, indicating the onset
of deterioration, and finally the fading away and entire
collapse of the delusions. Remissions in the symptoms
may occur. The outcome is always deterioration. The
rapidity with which the dementia develops varies greatly.
Usually some signs of dementia appear within two or three

Digitized byVjOOQlC


years. On the other hand, there are cases which deteriorate
within a few months, and there are others which do not
dement for a number of years.

In some cases the delusions gradually fade, are never ex-
pressed, are forgotten or wholly denied, and at the same
time there appears some insight. But in all these cases
there still remains some impairment of memory and judg-
ment, apathy, and a loss of the characteristic energy and
activity. Or the delusions and hallucinations may be re-
tained, while the patients become quite indifferent to them,
and rarely complain of persecutions or show agitation.
They are usually capable of emplo3rment, and sometimes
are even industrious, the former " Pope " becoming a trusted
farm-hand, and the " queen " a good seamstress.

More frequently the outcome is characterized by an in-
creasing confusion of thought, when the delusions become
more and more incoherent and unintelligible, while the
pecuharities of conduct increase with a tendency to occa-
sional states of excitement and impulsiveness. If the dete-
rioration advances further, the patients may reach a stage
of silly, quiet dementia.

Diagnosis of dementia prflecoz. — There are not only no
pathognomic signs of dementia praecox, but even some of the
more characteristic signs of the disease, such as, negativism, .
automatism, stereotypy, and mannerism, occur in other dis-
eases; for instance, paresis, senile and other organic psychoses,
as well as in some of the infection psychoses, and even in
manic-depressive and epileptic insanity. Hence the diagnosis
must rest on the entire picture and not upon any single
symptom. While it is possible that different disease pro-
cesses may exhibit at times similar groups of symptoms, it
is altogether improbable that these same diseases will at
all times resemble each other, both as regards the manner

Digitized byVjOOQlC


in which the symptoms develop, their course, and their out-

The slowly developing cases of hebephrenia must be
distinguished from acquired newrasthenia. This differentia-
tion depends especially upon the presence of signs of demen-
tia, the silliness of the hypochondriacal ideas, especially
sexual hypochondria, faulty judgment, emotional apathy,
and the fact that the patients do not improve with quiet and
relaxation. The emotional apathy of the hebephrenic
stands out in contrast to the increased emotional irritabiUty
of the neurastheniac. Finally, any evidences of hallucina-
tions, of automatism, or stereotypy distinctly indicate
dementia praecox (see also p. 155).

The differentiation of dementia praecox, occurring in mid-
dle hfe, from paresis in which the physical symptoms have
not yet appeared, may be quite difficult. The catatonic
symptoms that occasionally occur in paresis — catalepsy,
mutism, verbigeration, and stereotypy — are by no means
as varied and characteristic as in catatonia; while the general
incapacity and genuine weakness of will is more prominent
in contrast to the eccentricities and the unruliness of the
catatonic. Furthermore, the mental deterioration in paresis
is apt to be more rapid and more profound and character-
ized by greater disorder of the apprehension, orientation, and
impressibility of memory, while these faculties in compari-
son with the emotional stupidity and the weakness of judg-
ment in dementia praecox are retained for a relatively long
time, although they may be temporarily overpowered by neg-
ativism. The appearance of definite hallucinations and of
persistent mannerisms speaks for dementia praecox. The
speech disturbances of the paretic may be closely simulated
by the mannerisms of dementia praecox; even epileptiform
and apoplectiform attacks may occur in dementia praecox.

Digitized byVjOOQlC


In such doubtful cases one must depend upon the lymphocy-
tosis in the cerebrospinal fluid as determined by lumbar
puncture and the microscopic examination of the fluid
(see p. 103).

In the acutely developing cases of dementia praecox, the
clouding of consciousness and the confusion of speech often
render it difficult to distinguish amentia. Here one must
depend upon the presence of n^ativism, stereotypy, and
automatism. If the latter are present in amentia, they are not
marked. In amentia, the patients are more natural in their
acts, less constrained, and not silly and eccentric. The
orientation and impressibiUty of memory is far more dis-
tiu-bed in amentia than in dementia praecox. The amentia
patient, in spite of his best efforts, is unable to solve long
mental problems, loses the thread in long conversations, and
indulges in incoherent reminiscences, yet he is able to answer
some questions rapidly and to the point. On the other hand,
the dementia prsecox patient answers in a silly manner or
perhaps not at all. Again at times he surprises one by
his correct conversation, and his thoughtful, bright remarks,
or he even solves a difficult problem and recalls correctly
historical and geographical facts. In amentia the emotional
attitude is exceedingly changeable from depression to ex-
altation and vice versa, while in dementia prsBcox, even
during excitement, a certain emotional stolidity and apathy
prevails. The amentia patient may not have a very accu-
rate knowledge of the surroundings, yet he attends to and
watches what takes place; but in dementia praecox the pa-
tient exhibits remarkably Uttle interest in those things
that he comprehends well. Finally, in amentia there is
always a history of some exhausting etiological factor,
which only occasionally antedates dementia prsBcox.

Banning cases of catatonia may be mistaken for epileptic

Digitized byVjOOQlC


befogged states, particularly when an epileptiform attack has
occurred. The negativism of the catatonic contrasts with
the anxious resistance of the epileptic, while orientation is
much more disturbed in the epileptic. Silly answers to
simple questions and rapid and correct obedience to com-
mands speaks for catatonic. In epileptics an anxious or
ecstatic emotional attitude prevails. The epileptic is much
more apt to make frequent assaults and attempts at escape,
while the impulsive acts of the catatonic are purposeless
and manneristic.

The greatest difficulty arises in distinguishing the depres-
sive phases of manic-depressive insanity from the periods
of depression which one encounters at the onset of the hebe-
phrenic and the catatonic forms. The early appearance of
many hallucinations and senseless delusions, especially
ideas of physical influence, and the retention of a clear con-
sciousness speak for dementia praecox, as well as an emo-
tional attitude which does not correspond to the depressive
character of the delusions. The catatonic patient remains
quite indifferent during the visit of a relative, while in manic-
depressive depression the feelings are apt to be intensified.
Hypersuggestibility of the will may exist in both conditions,
but a manic-depressive patient will not upon request pro-
trude his tongue for the purpose of having it perforated with
a needle. The uniform lamentations that sometimes occur
in manic-depressive depression are the expressions of a
persistent and overwhelming feeling of sadness, and not
the result of a senseless persevering impulse. The condi-
tions of negativism of the catatonic and of anxious resist-
ance and retardation of the manic-depressive are at times
distinguished only with difficulty. In the former there is
uniform, rigid, and stubborn resistance to every passive
movement, and if pain is produced by pricking the eyelid,

Digitized byVjOOQlC


there is a simple withdrawal without effort at defence;
while in retardation the passive movements are mostly
permitted. In case the retarded patient shows some resistance
he does not persist in returning his hand to the same position,
and if one threatens to approach him he utters an outciy,
shrinks back, or defends himself. Voluntary movements
in catatonic stupor are rare, but when executed are carried
out without delay, and at times even rapidly, except when
these movements are made by request, then there is always
delay. In retardation, all voluntary movements are carried
out very slowly. There is sometimes a certain resistance
due to apprehension and fear, but this is active.

The differentiation between manic-stupor and catatonic
stupor is quite diflficult and depends upon the character-
istic happy temperament, distractibility of the attention
by the environment, the susceptibility to command, the
accessibility to conversation, and finally the occasional
purposeful and frolicsome character of the movements of
manic-stupor in contrast to the silliness, indifference, in-
susceptibility, and the senseless impulses of the catatonic

The excitement of the catatonic is to be distinguished
from (he excitement of (he manic phases of manic-depressive
insanity. In the catatonic excitement the clouding of con-
sciousness is less marked than in the manic excitement,
the patients being partially oriented, even in the greatest
excitement, while in the extreme manic states there is
complete disorientation. On the other hand, the speech of
the catatonic who has less motor excitement is more senseless
and diflScult to follow than that of the manic who has ex-
treme motor excitement. The catatonic speech abounds in
verbigerations and stereotyped expressions and is free of com-
ments upon the surroundings, while the speech of the manic

Digitized byVjOOQlC


presents the characteristic flight of ideas, and is centered
upon, or drawn largely from, the immediate surroundings.
Also attention is readily distracted by the surroundings,
while the attention of the catatonic cannot be. The emo-
tional attitude of the manic is exalted, frolicsome, and
irritable, while that of the catatonic is silly, childishly
happy, and indifferent. The movements of the catatonic
are purposeless, frequently repeated, in contrast to the press-
ure of activity of the manic, in whom the movements are
always purposeful, related to the surroundings, dependent
upon ideas, impressions, and emotions, and always appearing
in new forms. In catatonia there is no parallel between the
excitement in speech and that in movement; for instance,
the patient may be extremely productive, lying quietly in
bed, or he may be extremely active and not utter a word.
The increased activity of the catatonic is more apt to be
limited to one comer of the room or of the bed, while that
of the manic is limited only by his confines, and in addition
to this the individual movements of the catatonic tend to be
manneristic, stilted, unnatural, and associated with silly
impulses; those of the manic, natural and more compre-

The extreme excUemerU of the paretic may resemble closely
the catatonic excitement. In addition to the history of the
development of the disease, the age, and the physical signs,
paresis may be recognized by the more profound clouding
of consciousness, the greater disorientation, and disorder
of the impressibility of memory.

Dementia prsecox, especially where there have been hjrs-
terical attacks, must frequently be differentiated from

Online LibraryEmil KraepelinClinical psychiatry: → online text (page 21 of 45)