Chapter 16

SUMMARY OF THE STUPOR REACTION

Having discussed in detail the various symptoms and theoretic aspects of the benign stupors, it may be well to have these observations and speculations summarized.

It being established that stupors occur as a temporary form of insanity[12] psychiatry is faced at once with the problem of describing these conditions accurately in order to ascertain their nosological position. To this end we first examined typical cases of deep stupor and found that the clinical picture is made up of the following symptoms: In the foreground stands _poverty of affect_. The patients are almost unbelievably apathetic, giving no evidence by speech or action of interest in themselves or their environment, unmoved even by painful stimuli. Their faces are wooden masks; their voices as colorless when words are uttered. In some cases sudden mood reactions break through at rare intervals. The second cardinal symptom is _inactivity_. As a rule there is a complete cessation of both spontaneous and reactive movements and speech. So profound may this inhibition be that swallowing and blinking of the eyes are often absent. The trouble is not a paralysis, however, for reflexes without psychic components are unaffected. Possibly related to the inactivity is the preservation of artificial positions which is called _catalepsy_, a fairly frequent phenomenon. A tendency opposite to the inactivity is seen in _negativism_. This perversity is present in all gradations from outbursts of anger with blows and vituperation to sullen, or even emotionless, muscular rigidity. This last occurs most often when the patient is approached but may be seen when observations are made at a distance. Frequently _wetting_ and _soiling_ are due to negativism, when the patient has been led to the toilet but relaxes the sphincters so soon as he leaves it. A constant feature is a _thinking disorder_. On recovery memory is largely a blank even for striking experiences during the psychosis and, when accessible during the stupor to any questioning, a failure of intellectual functions is apparent. An _ideational content_ may be gathered while the stupor is incubating, during interruptions, or from the recollections of recovered patients. Its peculiarity is a preoccupation with the theme of death, which is not merely a dominant topic but, often, an exclusive interest. Probably to be related to this is a tendency, present in some cases, to sudden suicidal impulses, that are as apparently planless and unexpected as the conduct of many catatonics. Finally the disease is prone to exhibit certain _physical_ peculiarities. A low fever is common and so are skin and circulatory anomalies. A loss of weight is the rule, and menstruation is almost always suppressed.

As to the frequency of stupor no figures are available, for the simple reason that the diagnosis in large clinics has not been made with sufficient accuracy to justify any statistics. Most of these cases are usually called catatonia, depression, allied to manic-depressive insanity or allied to dementia præcox. The majority of the stupors reported in this book were in women, but this is merely the result of chance, since it has been easier in the Psychiatric Institute to study functional psychoses in the female division, while the male ward has been reserved largely for organic psychoses. The majority of the patients seem to be between 15 and 25 years of age, so that it is, presumably, a reaction of youthful years. In our experience most cases occur among the lower classes, which agrees with the opinion of Wilmanns who found this tendency among prisoners.

This gives a brief description of the deep stupor. But even our typical cases did not present this picture during the entire psychosis. They showed phases when, superficially viewed, they were not in stupor but suffered from the above symptoms as tendencies rather than states. There are also many psychoses where complete stupor is never developed. This gives us our justification for speaking of the _stupor reaction_, which consists of these symptoms (or most of them) no matter in how slight a degree they may be present. The analogy to mania and hypomania is compelling. The latter is merely a dilution of the former. Both are forms of the manic reaction. We consequently regard stupor and partial stupor as different degrees of the same psychotic process which we term the stupor reaction. To understand it the symptoms should be separately analyzed and then correlated.

The most fundamental characteristic of the stupor symptoms is the change in affect which can be summed up in one word--apathy. It is fundamental because it seems as if the symptoms built around apathy constitute the stupor reaction. The emotional poverty is evidenced by a lack of feeling, loss of energy and an absence of the normal urge of living. This is quite different from the emotional blocking of the retarded depression, for in the latter the patient shows either by speech or facial expression a definite suffering. The tendency to reduction of affect produces two effects on such emotions as internal ideas or environmental events may stimulate. Exhibitions of emotion are either reduced or dissociated. For instance, anxiety is frequently diminished to an expression of dazed bewilderment; or, isolated and partial exhibitions of mood occur, as when laughter, tears or blushing are seen as quite isolated symptoms. This latter--the dissociation of affect--seems to occur only in stupor and dementia præcox. It should be noted, however, that inappropriateness of affect is never observed in a true benign stupor. A final peculiarity is the tendency to interruption of the apathetic habit, when the patient may return to life, as it were, for a few moments and then relapse.

Closely related to the apathy, and probably merely an expression of it, is the inactivity which is both muscular and mental. It exists in all gradations from that of flaccidity of voluntary muscles, with relaxation of the sphincters, and from states where there is complete absence of any evidence of mentation to conditions of mere physical and psychic slowness. After recovery the stupor patient frequently speaks of having felt dead, paralyzed or drugged.

By far the commonest cause of emotional expression or interruption in the inactivity is negativism. This is a perversity of behavior which seems to express antagonism to the environment or to the wishes of those about the patient. In the partial stupors it is seen as active opposition and cantankerousness. In the more profound conditions it is represented by muscular resistiveness or rigidity, or refusal to swallow food when placed in the mouth. Occasionally, too, the patient may even in a deep stupor retain urine so long that catheterization is necessary. All the explanations which one may gather from the patients’ own utterances, mainly retrospective, seem to point to negativism expressing a desire to be left alone. The appearance of perverse behavior in aimless striking or mere muscular rigidity seems to be an example of dissociation of affect.

Catalepsy is an important symptom because, although it occurred in slightly less than a third of our cases, it seems to be a peculiarity of the stupor reaction found but rarely in other benign psychoses. It seems never to occur without there being some evidence of mental activity, and, consequently, we are forced to conclude that it is of mental rather than of physical origin. Just what it means psychically it is impossible to state without much more extended observations. We conjecture tentatively, however, that the retention of fixed positions is in part merely a phenomenon of perseveration, and in part an acceptance of what the patient takes to be a command from the examiner, and sometimes a distorted form of muscular resistiveness.

The intellectual processes suffer more seriously in stupor than in any other form of manic-depressive insanity. Not only do the deep stupors betray no evidence of mentation during the acme of the psychosis, but retrospectively they usually speak of their minds being a blank. Incompleteness and slowness of intellectual operations are highly characteristic features of the partial stupors and of the incubation period of the more profound reactions. The features of this defect are a difficulty in grasping the nature of the environment, a slowness in elaborating what impressions are received, with resulting disorientation, poor performance of any set tests and incomplete memory for external events when recovery has taken place. At times the thinking disorder may develop with great suddenness or improve as quickly, and a tendency to isolated evidences of mental acuity is another example of the inconsistency which is so highly characteristic of stupor. We should note, however, that these sporadic exhibitions of mentality are always associated with brief emotional awakening.

When we turn to examine the fragmentary utterances of stupor patients, we are surprised by the narrowness and uniformity of the ideational content. It seems to be confined to thoughts of death or closely related conceptions. Thirty-five out of thirty-six consecutive cases at one time or another referred literally to death. It is commonest during the onset, as all but five of these patients spoke of it during the incubation of their psychoses. Hence we conclude that death ideas and stupor are consecutive phenomena in the same fundamental process. As two-thirds of the series interrupted the stupor to speak of death or to attempt suicide, we assume that this relationship persists. Only a quarter gave any retrospective account of these fancies, so we presume that their psychotic experiences were repressed with recovery.

The usual form in which the idea appears is as a delusion of going to die or, literally, of being dead. It may appear as being in Heaven or Hell. A theoretically important group is that which includes the patients who, in addition, speak of being in situations such as under the water or underground, which we have mythological and psychological evidence to believe are formulations of a rebirth fantasy. Not rarely, preoccupation with death is expressed in sudden impulsive suicidal attempts.

The affective setting of these different formulations is important. A delusion of literal death occurs with complete apathy. The wish to die is apt to appear without the usual accompaniment of sadness or distress but still with considerable energy when impulsive suicidal attempts are made. A prospect of death, particularly when there is anticipation of being killed, is apt in manic-depressive insanity to occur in a setting of anxiety. Similarly one ordinarily observes fear in the patient who has delusions of drowning or burial. In the stupor cases, however, this painful affect seems to be reduced to a mere dazed bewilderment or feeble exhibitions of a desire for safety, such as the slow swimming movements of a patient who thought she was under the water. When these ideas of danger become allied to everyday interests--husband or child imperiled, etc.--a weak affect in the form of depression is apt to occur.

Physical symptoms are more common than in any other benign psychosis. Of these the most nearly constant is a low fever, the temperature running between 99° and 101°. Twenty-eight out of thirty-five cases had this slight elevation with a tendency for it to occur immediately at the beginning of marked stupor symptoms. Although the evidence does not positively exclude any possibility of infection, it speaks distinctly against this view. A possible explanation is that the low fever is a secondary symptom. The suprarenal glands may function insufficiently as a consequence of the emotional poverty, since all emotions which have been experimentally studied seem to stimulate the production of adrenalin. Without this normal hormone for the activity of the sympathetic nervous system, there would be a disturbance of skin and circulatory reactions that would interfere with the normal heat loss. Suggestive evidence to support this view comes from the frequency with which the extremities are cyanotic or cold, the skin greasy, sweating profuse or absent, and so on. Further observations are necessary to confirm or disprove this hypothesis, but we feel inclined to accept it tentatively because it is plausible and consistent with the view that stupor is essentially a psychogenic type of reaction. Another physical anomaly, which is presumably of endocrine origin, is the suppression of the menses. This probably results from lowered nutrition. In some cases it ensues directly on a psychic crisis before any nutritional change can have taken place. Finally, among the symptoms of possible physical origin, epileptoid attacks were described in two of our cases. This is chiefly of interest in that such phenomena are extremely rare in the benign psychoses.

We believe that the mental symptoms summarized above constitute a specific psychotic type of reaction capable of appearing in any severity from mere lethargy and indifference to profound stupor. Since the prognosis is good, we feel obliged to classify this with the manic-depressive reactions. Further justification for this grouping is found in the occurrence of the stupor reaction as a phase in many manic-depressive psychoses. A patient may swing from mania to stupor as from mania to depression, and when the partial stupors are recognized as milder forms of the same process, it seems to be a frequent type of reaction.

If stupor be a reaction type, its laws must be psychological. According to the view of modern psychopathology, the essence of insanity is regression with indolent thinking as opposed to progressive and energetic mentation. One can look on stupor as being a profound regression. Effort is abandoned (apathy and inactivity), while the ideational content expresses a desire for a retreat from the world in death. It is possible to think of this regression as a return to the mental habit of the suckling period, when spontaneous effort is at its minimum. This, too, is the time when petulance and tantrums are frequent expression of a wish to be left alone, which may account for the negativism as a consistent symptom of the same regressive progress.

Just as we regress in sleep, to rise refreshed for a new day’s duties, so the stupor case often shows excessive energy in a hypomanic phase before complete normality is reached. This corresponds again to the age-old association of the ideas of death and rebirth which we see together so frequently in stupor. It is the psychology of wiping the slate clean for a fresh start.

The development and symptoms of stupor furnish evidence in support of the hypothesis of this type of regression. Dissatisfaction of any kind is the setting in which the psychosis begins and the commonest precipitating factor is some reminder of death. That loss of energy appears with the stupor is evident from the inactivity and apathy, while the thinking disorder can be shown to be the result of the same loss. The different “levels” of the stupor reaction also conform to a theory of regression. First there is mere indifference and quietness; then appear false ideas when normality is so far abandoned as to mean a loss of the sense of reality; withdrawal of interest from the environment, with its consequent centering of self, leads to the next stage--that of the spoiled child reaction; then follows the exclusion of the world around in the dramatization of death; finally, in the deepest stupor, mentation is so far abandoned that we can gather no evidence of even this delusion being present.

Atypical features in stupor have to do mainly with interruptions, interludes as it were, of elation, anxiety or perplexity. These are explicable as awakenings from the nothingness of stupor into imaginations such as characterize the other manic-depressive psychoses. When such tendencies are present, the co-existence of the stupor process may tone down the emotional response or prevent its complete repression so that insufficient or dissociated affects appear. A combination of the stupor tendency to apathy with the mood of another reaction is probably the only combination of affects to be met with in psychiatry.

The stupor reaction, then, is a simple regression, with a limitation of energy, emotion and ideational content, the last being confined to notions of death. All functional psychoses are regressions. How do the others differ from this? We need only answer this question in so far as it concerns the clinical states resembling benign stupors. Stupors occur frequently in catatonic dementia præcox. In this disease there is a regression of interest to primitive fantastic thoughts, and with this a perversion of energy and emotion. This corrupts the purity of the stupor picture so that inconsistencies, such as empty giggling, atypical delusions and scattered speech, occur. Other impurities are to be found in the frequent orientation of the dementia præcox stupor patient which is discovered to be astonishingly good, or in free speech associated with apathy and inactivity. Such symptoms usually appear quite early and should enable one to make a positive diagnosis within a short time after patient comes under observation. As a matter of fact, in many if not most cases there is a slow onset characterized by the pathognomonic symptoms of dementia præcox before the actual stupor sets in.

Other psychoses superficially resembling stupor are the perplexity and absorbed manic (manic stupor) states. We have reason to believe that both these conditions are essentially the result of absorption in kaleidoscopic ideas. Their appearance is that of inactivity and indifference to the outside world, just as a dreamer seems placid and apathetic. But these reactions are not without emotion which may sometimes be obvious, and the richness of the mental content is sooner or later manifest.

Finally, from a practical standpoint, an important peculiarity of benign stupor is the tendency for response to stimulation in amelioration of the process. Close attention to these patients is advisable, therefore, not merely for the sake of their physical health, but also because any attention tends to keep them mentally alive or revive their waning energy. Visits of relations often initiate recovery in a striking way. From occurrences such as these, psychiatrists should gain hints for valuable therapeutic experiments.

So much for the technical, psychiatric aspects of the stupor problem. We have frequently spoken of it, however, as a psychobiological reaction. If this be a sound view, similar tendencies should appear in everyday life, the psychotic phenomena being merely the exaggerations of a fundamental type of human and animal behavior. Shamming of death in the face of danger and animal catalepsy come to mind at once, but since we know nothing of the associated affective states we should be chary of using them even as analogies. We are on safer ground in discussing problems of human psychology.

It is evident that there are psychological parallels between the stupor reaction and sleep, while future work may show physiological similarities as well. Apathy towards the environment, inactivity and a thinking disorder are common to both. But sleep reactions do not occur in bed alone. Weariness produces indifference, physical sluggishness, inattention and a mild thinking disorder such as are seen in partial stupors. The phenomena of the midday nap are strikingly like those of stupor. The individual who enjoys this faculty has a facility for retiring from the world psychologically and as a result of this psychic release is capable of renewed activity (analogous to post-stuporous hypomania) that cannot be the result of physiological repair, since the whole affair may last for only a few minutes.

In everyday life there are more protracted states where the comparison can also be made. When life fails to yield us what we want, we tend to become bored--a condition of apathy and inactivity, forming a nice parallel to stupor inasmuch as external reminders of reality and demands for activity are apt to call out irritability. A form of what is really mental disease, although not called insanity, is permanent boredom, a deterioration of interest, energy and even intelligence by which many troubled souls solve their problems. A sudden withdrawal from the world we call stupor. When the same thing happens insidiously, the condition is labeled according to the financial and social status of the victim. He is a bum, a loafer, a mendicant or, more politely, a disillusioned recluse. Frequently this undiagnosed dement has satisfied himself with a weak, cynical philosophy that life is not worth while.

It is but a step from valueless life to death and the same tendency which makes the patient fancy he is dead, leads the tired man to sleep, the poet to sigh in verse for dissolution, and the myth maker to fabricate rebirth. The religions of the world are full of this yearning, which reaches its purest expression in the belief and philosophy of Nirvana. The ideational content of stupor has also its analogue in crime. The desire for perpetuation of relationships unprosperous in this world is not seen only in the delusion of mutual death. One can hardly pick up a newspaper without reading of some unhappy man or woman who has slain a disillusioned lover and then committed suicide.

FOOTNOTES:

[12] Kirby, George H.: “The Catatonic Syndrome and Its Relation to Manic-Depressive Insanity.” _Jour. of Nervous and Mental Disease_, Vol. XL, No. 11, 1913.