Chapter 12

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.