Chapter 6

THE INTERFERENCES WITH THE INTELLECTUAL PROCESSES

This is one of the most interesting and important of the stupor symptoms. We are accustomed to think of the functional psychoses having symptoms to do with emotions and ideas in the main, and, conversely, that disorientation, etc., observed in such cases is merely the result of distraction, poor attention or coöperation. But in stupor the deficit in understanding, incapacity to solve simple problems and failure of memory seem deep-rooted and fundamental symptoms. So far is this true that Bleuler[5] looks on “schizophrenic” cases with this symptom of “Benommenheit” as organic in etiology. It may be said at the outset that we do not share this view for many reasons. One at least may now be stated as it seems to be final. In benign stupor purely mental stimuli may change the whole clinical picture abruptly and with this produce a change in the intellectual functioning such as we never see in organic dementias or clouded states. We find it more satisfactory to attempt a correlation of this with the other symptoms on a purely functional basis, as will be explained later.

For the study of the interferences with the intellectual processes during stupor reaction, we have two sources of information: The first is derived from the account which the patient is able to give in regard to what he remembers as having taken place around him or in his mind during the stupor period; the second is the direct observation of partial stupor reactions.

1. Information Derived from the Patient’s Retrospective Account

We will start with the cases of marked stupor mentioned in Chapter I. Anna G.’s (Case 1) psychosis commenced at home, and under observation lasted with great intensity for five months. She remembered only vaguely the carriage going to the Observation Pavilion, had no recollection of the latter, nor of her transfer to the Manhattan State Hospital and of most of the stay at the Institute ward, including the tube- or spoon-feeding which had to be carried on for four months. She also claimed that she did not know where she was until four or five months after admission. She was amnesic for her delusions and hallucinations. Of Caroline DeS. (Case 2) we have no information. Of Mary F. (Case 3), whose stupor began at home and under observation lasted two years, we find that she had no recollection of coming to the hospital, what ward she came to, who the doctor and nurses were (with whom she became acquainted later), in fact she claimed that for about a year she did not know where she was. But she remembered having been tube-fed (this took place over a long period). Mary D.’s (Case 4) stupor also commenced at home, and under observation lasted for three months. She had no recollection of going to the Observation Pavilion, of the transfer to Manhattan State Hospital, and of a considerable part of her stay here, including such obtrusive facts as a presentation before a staff meeting, an extensive physical and a blood examination, and she claimed not to have known for a long time where she was. Annie K.’s (Case 5) stupor commenced at home. Although she recalled the last days there and some ideas and events at the Observation Pavilion, the memory of the journey to Ward’s Island was vague, as was that of entrance to the ward, and she claimed not to have known where she was for quite a while. Specific occurrences, such as the taking of her picture (with open eyes two months after admission), an examination in a special room, her own mixed-up writing (end of second week) were not remembered. But it is quite interesting that an angry outburst of another patient within this same period, which was evidently not recorded, is clearly remembered.

We shall later show that when the patient comes out of a stupor the condition may be such that, for a time at least, retrospective accounts are difficult to obtain. It must also be remembered that not infrequently the more marked stupors may be followed by milder states, and it is important, if we wish to determine how much is remembered, not to confuse the two states or not to let the patient confuse them. For example, Mary D. (Case 4), who showed two separate phases, while she claimed not to know of many external facts, also added that she could not understand the questions which were asked. From observation in other cases it seems that in marked stupor any such recollection about the patient’s own mental processes would be quite inconsistent. We have to assume, therefore, that this remark referred in reality to the second milder phase, for which, as we shall see, it is indeed quite characteristic. It is not necessary to burden the reader with other cases, all of which consistently gave such accounts.

We see, then, that in the marked stupor the intellectual processes are regularly interfered with, as evidenced by almost complete amnesia for external events and internal thoughts. In other words, this would indicate that the minds of these patients were blank. Inasmuch as direct observation during the stupor adduces little proof of mentation, we may assume that such mental processes as may exist in deepest stupor are of a primitive, larval order.

Before we examine more carefully the milder grades of stupor, it will be necessary to say a few words about the retrospective account which the patient gives of intellectual difficulties during the incubation period of the psychosis. As a matter of fact, we find that these accounts are remarkably uniform. While some patients, to be sure, speak of a more or less sudden lack of interest or ambition which came over them, others of them speak plainly of a sudden mental loss. Mary. C. (Case 7) claimed she suddenly got mixed up and lost her memory. Laura A. spoke at any rate of suddenly having felt dazed and stunned. Mary D. (Case 4) said she felt she was losing her mind and that she could not understand what she was reading. Maggie H. (Case 14) began to say that her head was getting queer. We see from this that the interferences with the intellectual processes may in the beginning be quite sudden.

In some instances a more detailed retrospective account was taken, which may throw some light upon the interferences with the intellectual processes with which we are now concerned. Emma K., whose case need not be taken up in detail, had a typical marked stupor which lasted for nine months, preceded by a bewildered, restless, resistive state for five days. She was in the Institute ward for the first four months, including the five days above mentioned; later in another ward. When asked what was the first ward which she remembered, she mentioned the one after the Institute ward, and when asked who the first physician was, she mentioned the one in charge of the second ward. However, when taken to the Institute ward, she said it looked familiar, and was able to point to the bed in which she lay, though somewhat tentatively. The same rousing of memory occurred when the first physician, who saw her daily, was pointed out to her. She remembered having seen him, and then even recalled the fact that he had thrown a light into her eyes, but remembered nothing else. This observation would seem to show that with some often repeated or very marked mental stimuli (throwing electric light into her eyes) a vague impression may be left, so that it may at least be possible to bring about a recollection with assistance, whereas spontaneous memory is impossible. In another instance, the patient was confronted with a physician who had seen a good deal of her. She said that he looked familiar to her, but she was unable to say where she had seen him. Here then again evidence that a certain vague impression was made by a repeated stimulus.

Another feature should here be mentioned, namely, that isolated facts may be remembered when the rest is blank. We have seen above that Annie K. (Case 5), while very vague about most occurrences, recalled a sudden angry outburst in detail. Another patient, though the period of the stupor was a blank, recalled some visits of her mother. At these times, as she claimed, she thought she was to be electrocuted and told her mother so, “Then it would drop out of my mind again.” These facts are very interesting. We can scarcely account for such phenomena in any other way than by assuming that certain influences may temporarily lift the patient out of the deepest stupor. In spite of the fact that stupors often last for one or two years almost without change, a fact which would argue that the stupor reaction is a remarkably set, stable state, we see in sudden episodes of elation that this is not the case, and other experiences point in the same direction. A similar observation was made on a case of typical stupor with marked reduction of activity and dullness. A rather cumbersome electrical apparatus (for the purpose of getting a good light for pupil examination) was brought to her bedside. Whereas before, she had been totally unresponsive, she suddenly wakened up, asked whether “those things” would blow up the place, and whether she was to be electrocuted. During this anxious state she responded promptly to commands, but after a short time relapsed into her totally inactive condition. We have, of course, similar experiences when we try to get stuporous patients to eat, who, after much coaxing may, for a short time, be made to feed themselves, only to relapse into the state of inactivity.

Such variations are paralleled, as we shall later show, by a suddenly pronounced deepening of the thinking disorder. We have already seen that the onset may be quite sudden. All this indicates that, in spite of a certain stability, sudden changes are not uncommon. Finally, we know that, in spite of the fact that stupor is an essentially affectless reaction, certain influences may produce smiles or tears, or, above all, angry outbursts, which again can hardly be interpreted otherwise than by assuming that those influences have temporarily produced a change in the clinical picture, in the sense of lifting the patient out of the depth of the stupor. All these facts suggest that inconsistencies in recollection are correlated with changes in the clinical picture.

As is to be expected, the cases with partial stupors remember much more of what externally and internally happened during their psychoses. Rose Sch. (Case 6), who had a partial stupor during which she answered questions but showed a great difficulty in thinking, said retrospectively that she felt mixed up and could not remember. Although she recalled with details the Observation Pavilion and her transfer, she was not clear about their time relations (how long in the Observation Pavilion, how long in the first ward). Mary C. (Case 7), whose activity was not entirely interfered with and who showed some thinking disorder, said retrospectively that she could not take in things. Henrietta H. (Case 8), who had a partial stupor, claimed to have known all along where she was, but that she felt mixed up, that her thoughts wandered and that she felt confused about people. In the cases where a partial stupor was preceded by a marked one, such as in phase 2 of Anna G. (Case 1) and phase 2 of Mary D. (Case 4), we have no retrospective account regarding the partial stupor, because emphasis in the analysis was naturally laid on the period comprising the most marked disorder. However, we can gather from the few cases at our disposal that the patients retrospectively lay stress chiefly on their inability to understand the situation.

We finally have to consider the group of suicidal cases. We have information only in regard to two cases, namely, Margaret C. (Case 10) and Pearl F. (Case 9). In both of these, we find that a good many things that happened during the period under consideration were remembered, as were also the patients’ own actions. In Rosie K. (Case 11) we have at least the evidence that she remembered her own impulses, namely, that she refused food because she wanted to die. In other words, in these partial stupors with impulsive suicidal tendencies the interference with the intellectual processes seems to be moderate, and memory for external events not markedly affected.

2. Information Derived from Direct Observation

The evidence can best be presented by considering the details of some cases.

Rose Sch. (Case 6) was remarkable, in connection with the present problem, in her unusually poor answers. She either merely repeated the questions, or made irrelevant superficial replies, or said she did not know, this even with very simple questions. When better, too, though not quite well, she showed striking discrepancies in time relations and incapacity to correct them. It would seem that in this case there was something more than an acute interference with the intellectual processes, such as we are here discussing. As a matter of fact, we have the statement in the history that the patient herself said she was slow at learning in school and had not much of an education. A congenital intellectual defect and the attitude which it creates may, however, as my experience has repeatedly shown me, very greatly exaggerate an acute thinking disorder. The case, therefore, while it shows us an unquestionably acute interference with the intellectual processes, does not give us useful information about its nature. More information can be gathered from Mary D. (Case 4). Even toward the end of her marked stupor some replies were obtained chiefly by making her write. When asked to write Manhattan State Hospital, she wrote Manhatt Hhospshosh, and for Ward’s Island, Ww. Iland. Again, instead of writing 90th Street, she wrote 90theath Street. These are plainly reactions of the path of least resistance or, in these instances, of perseveration. Of the same nature are some of her other replies in writing or speaking. After she had been asked to write her name, she was requested to add her address, or the name of the hospital; she merely repeated the name. Similarly, when asked whether she knew the examiner, she said “Yes,” but when urged to give his name, she gave her own. In the partial stupor at a time when she knew where she was, knew the names of some people about her, the year and approximately the date, she made mistakes in calculation and could not get the point of a test story. Moreover, she failed in retention tests without there being any evidence of anything like a marked fundamental retention disorder, such as we find in Korsakoff psychosis. It seems that these results are best termed defects in attention, which chiefly interfere with the apprehension of more difficult tasks. As we shall see later, this seems to be rather characteristic of these cases. Another point which should be mentioned is the fact that her reaction to questions which she was unable to answer (such as matters which referred to her amnesic periods) was peculiar, inasmuch as she did not only not try to think them out, but seemed indifferent to her incapacity, simply leaving the question unanswered. This too, as we shall see later, is characteristic. Laura A., at a time when she could be made to reply, merely repeated the question, again a reaction of least resistance. The same patient sometimes asked, “Where am I?” Mary C. (Case 7) made similar queries. Although she was at times approximately oriented, she would say, “I don’t know where I am,” or “I can’t realize where I am,” or more pointedly, “I can’t take in my surroundings.” She often did not answer and sometimes seemed bewildered by the questions. Henrietta H. (Case 8) again showed some defect of orientation and mistakes in calculation, and above all, marked mistakes in writing (for Manhattan State Hospital--Manhaton Hotspal). A special feature here is that this occurred immediately after she had been quite talkative, but suddenly had relapsed into a dull state. Anna G. (Case 1), during the third phase of her psychosis, showed the following: Although she was approximately oriented and answered promptly simple questions; e.g., about orientation or simple calculation, she, like these other patients, simply remained silent when more difficult intellectual tasks were required of her (more difficult calculations); or when she was asked how long she had been here (which involved data that could not be available to her, owing to her amnesia); or when questions were put to her regarding her feelings or the condition she had passed through. On the other hand, she sometimes gave appropriate replies in the words “yes” or “no,” but it was difficult to say whether these answers did not also represent the path of least resistance.

We will finally take up the last phase of Margaret C. (Case 10). Although she was entirely oriented, there was a certain vagueness about her answers which is difficult to formulate. She was telling about the onset of her sickness and said that at that time her mind was taken up with prayers about the salvation of her relatives. She was asked exactly when it was that she thought of this and she answered “Now?” (What period are we talking about?) “The present.” (What did I ask you?) “About this period of my sickness.” (Which one?) “What sickness?” She said herself at this point, “I am rather stupid.” Again when asked how her mind worked, she said, “Pretty quickly sometimes--I don’t know.” (As good as it used to?) “No, I don’t think so.” (What is the difference?) “There is no difference.” (What did I ask you?) “The difference.” (The difference between what?) “You did not say.” In this the shallowness of her comprehension and thinking is well shown, and it seems here again perhaps justifiable to formulate the main defect as one of attention, which prevents completion of a complicated process of comprehension. A feature of further interest in this case is that automatic intellectual processes, such as those necessary for the writing of a long poem from memory, were not interfered with.

Summary

In the most pronounced stupor we have evidently a more or less complete standstill in thinking processes. Practically no impressions are registered and consequently nothing is remembered except events that occurred in some short periods when some affective stimulus, or a brief burst of elation, lifts the patient temporarily out of the deep stupor. It is impossible to say whether the statement of a complete standstill has to be qualified. In some stupors repeated environmental stimuli sometimes make at least a vague impression, so that while spontaneous recollection is impossible a feeling of familiarity is present when the patient is again confronted with this environment. This might be an exception to the dictum of complete mental vacuity, or it may be that there are somewhat less pronounced stupor reactions. When more is perceived, there is often a retrospective statement of having felt mixed up, being unable to take in things, or, directly under observation, the patient may say, “I cannot realize where I am,” “I cannot take in my surroundings.” In harmony with this is the fact that questions often produce a certain bewilderment. In quite pronounced states in which some replies can still be obtained, we find that the intellectual processes may be interfered with to the extent of a paragraphia, i.e., a remarkably mixed-up writing in which perseveration (one form of following the path of least resistance) plays a prominent part. This same principle is also seen in such reactions as the repetition of the question or the senseless repetition of a former answer. These phenomena remind us of what we see in epileptic confusions, in epileptic deterioration and in arteriosclerotic dementia.

In milder cases difficulties in orientation may be more or less marked; or there may be incapacity to think out problems, although the orientation is perfect. The more automatic mental processes may run smoothly (memory and calculation may be excellent) and there may yet be a certain shallowness in thinking, a defect of attention (a purely descriptive term) which is most obvious in the patient’s inability to grasp clearly the drift of what is going on or the meaning of complicated questions. I am inclined to think that poor results in retention tests are entirely due to this attention disorder, for we have no evidence of any fundamental retention defect such as we find in the totally different organic stupors. From a practical point of view it is important at this place to call attention to the fact that such mild changes are particularly seen in end stages. Even when pronounced negativistic tendencies do not play a prominent rôle, the patient is then apt to be silent chiefly as a result of the residual disorder in the intellectual processes. Still more striking are the conditions which are on a somewhat higher level and in which the shallowness of the responses, due to the residual disorder of attention, together with the last traces of the affectlessness, are apt to create the impression of a dementia. In such cases the opinion is often held that the patient has reached a defect stage from which recovery is impossible, whereas a thorough knowledge of these end stages teaches us that they are not only recoverable but quite typical for the terminal phases of stupor.

Considering these data, especially those gathered in the end stages, it would appear that there is no tendency in this intellectual disorder associated with the stupor reaction for any special side of mental activity to be most prominently affected. It looks rather as if it were a question of a general diminution of the capacity to make a mental effort which in its different intensities accounts for the symptoms.

FOOTNOTES:

[5] See Chapter XV.