Chapter 8

AFFECT

The most constant and significant symptom in the stupor reaction is the change in affect. This extends from mere quietness in the mildest phases of the disease through the stage of indifference where apathy replaces the normal reactions of the personality, to the final condition of complete inactivity in the vegetative stupor where all mental life seems to have ceased. It seems as though there were, as a pathognomonic sign of the morbid process, a lack of energy and loss of the normal _élan vital_.

We may say, in fact, that the establishment of a specific type of emotional change is justification for classifying all milder stupor reactions with the deep stupors. In other words, our reason for the enlargement of the stupor group to include all apathetic reactions (except those of dementia præcox) is the belief that this dulling of the emotional response is as specific a type of emotional change as is anxiety, depression or elation. Perhaps it would be more accurate to say that this clinical group is founded on the symptom complex which is built around apathy. There is never any resemblance between apathy and the mood of elation or anxiety. A discrimination from depression is the only differentiation worth discussion.

The first point that should be made is that there is a difference between marked depression and the mood of stupor. In the former we get a retardation with a feeling of blocking, rather than of an absence of energy. The expression of the patient is one of dejection, not of vacancy, which bespeaks a mood of sadness, even when the patient is so retarded as to be mute and therefore incapable of describing his emotions. Running through all the stages of stupor, however, there is an emptiness, an indifference that is in striking contrast to the positive pain that is felt or expressed by the depressed patient. It may be objected, of course, that this apathy really represents the final stage in the emotional blocking of the depressed individual, but the development of stupor and recovery from it shows an entirely different type of process. A deep depression recovers by changing the point of view from a feeling of unworthiness and self-blame to one of normality. The stuporous case, on the other hand, evidences merely less and less indifference, and more and more interest in his environment and in himself as he gets well.

The associated symptoms are no less dissimilar. The difficulty in thinking which troubles the depressed patient is slight in proportion to his emotional gloom, and he feels himself to be much more incompetent intellectually than examination proves him to be. On the other hand, in the stupor reaction we find that the thinking disorder runs hand in hand with the apathy and that the intellectual capacity of the patient is really markedly interfered with, as can be shown by more or less objective tests. A mere slowing of thought processes accompanied by subjective feeling of effort is the limit reached in true depression, while it is merely the beginning of the intellectual disorder in stupor, for one meets with retardation symptoms only in the partial stupors. The slowing in these cases seems to represent an early stage of the intellectual disturbance which reaches its acme in the mental vacuity and complete incompetence of the deep stupor, just as slow movements in the partial stupors seem to represent a diluted inactivity reaction. This actual thinking disorder is not present in those forms of manic-depressive insanity which are characterized by elation, anxiety or depression but is seen only in stupors, occasionally in absorbed manic states (manic stupor) and sometimes in perplexity states. The psychological mechanisms of this last group are probably analogous to those of stupor, but this is not the place for a discussion of this topic.

Another associated symptom whose manifestations differ in depression and stupor is that of unreality. In the former there is frequently a feeling of unreality that is purely subjective, whereas the stupor case does not usually complain of this but does exhibit a difficulty in grasping the nature of his environment, which the typical depressive case never has.

The occurrence of other mood reactions than apathy in the same patient is also characteristic. Manic states (usually hypomanic) frequently occur during the phase of recovery from the stupor. This is an unusual, although not unknown, phenomenon in recovery from severe retarded depressions. The circular cases who swing from depression to elation usually show the milder types of depressive reaction which would never be confused with stupor. On the other hand, deep stupors very frequently are terminated by manic reactions, and if not by such means, recovery seems to occur merely in virtue of a gradual attenuation of the stupor symptoms. Rarely do we see a change to depression or anxiety heralding improvement. This tendency of the stupor reaction to remain pure or change to hypomania is a peculiarity which seems to put stupor in a class by itself among the manic-depressive reactions, as all the other mood reactions frequently change from one to the other.

Although apathy is the central pathognomonic symptom of stupor conditions, there are other mood anomalies to be noted. One of these is the tendency for inconsistency in, as well as reduction of, the expression of emotion. For instance, in the states where one would expect anxiety during the onset of stupor or in its interruptions, manifestation of this anxiety is often reduced to an expression of dazed bewilderment. In the anxiety states associated with stupor one does not meet with the restlessness and expressions of fear which would be expected. Quite similarly, when a manic tendency is present, it occurs either in little bursts of isolated symptoms of elation (such as smiling or episodic pranks), or some of the evidences of elation which we would expect are missing. For instance, Johanna S. (Case 13) terminated her stupor with a hypomanic state which was natural except for her always wearing an expressionless face. Sometimes laughter occurs alone and gives the impression of a shallow affect, raising a suspicion of dementia præcox. In fact, such evidences of affect as do appear in the course of the stupor are apt to be isolated, queer and “dissociated.” It does not seem as if the whole personality reacted in the emotion as it does in the other forms of manic-depressive insanity. For example, we may think of the resistiveness which is so frequently present when the patient seems in other respects to be psychically dead. One may recall the case of Meta S. (Case 15), who, otherwise inert, was occasionally seen with tears or smiles. Anna G. (Case 1), too, was often seen smiling or weeping. It was noted once of Charlotte W. (Case 12) that she ceased answering questions and remained immobile with fixed gaze, but when some mention was made of her going home she flushed and tears ran down her cheeks, although no change in the fixedness of her attitude or facial expression was seen. When Johanna S. was visited by her daughter and was lying motionless in bed, she slowly extended her hands, apparently tried to speak, and then her eyes filled with tears. Two days later, at the end of an interview when she had made a few replies, she settled down into her usual inactivity and, when further urged to answer, her eyes filled with tears. Similarly, too, in fairly deep stupor pin pricking may result in flushing, in tears or an increased pulse rate without the patient giving any other evidence of the stimulus being felt. These examples seem to show a larval effort at normal human response which, failing of complete expression, appeared as single isolated features of emotion suggesting true dissociation. We should also in this connection bear in mind the impulsive suicidal acts which occur either as unexpectedly as the impulsiveness in a true dementia præcox patient, or in a setting of coarse animal-like excitement that seems quite unrelated to the personality. One is reminded of the patient who made suicidal attempts during the period when she shouted like a huckster, giving no evidence whatever by her expression or the tone of her voice of feeling anxiety, sorrow or any other normal emotion.

All these queer and larval affective reactions remind one strongly of dementia præcox. The resemblance of the benign stupor to certain dementia præcox types is not merely a matter of identity with catatonic features (catalepsy, negativism). In these anomalous mood reactions it seems as if there were a definite dissociation of affect, and so there is. How then can we differentiate these emotional symptoms from the “dissociation of affect” which is regarded as a cardinal symptom of dementia præcox? The answer is that this term is used too loosely as applied to the latter psychosis. It is a particular type of dissociation which is significant of the schizophrenic reaction, for in it there is an acceptance of what should be painful ideas evidenced either by incomplete manifestations of anxiety or depression or actually by smiling. We never see in dementia præcox the reverse--a painful interpretation of what would normally be pleasant. It is the pleasurable interpretation of what is really unpleasant that gives the impression of queerness in the mood of these deteriorating or chronic cases. In stupor, on the other hand, although this dissociation takes place, the mood is never inappropriate, merely incomplete in that all the components or the full expression of the normal reaction are not seen.

Our description of the mood reactions in stupor would be incomplete if we omitted to mention the occasional appearance of an emotional attitude not unlike that seen in many cases of involution melancholia, which reminds one in turn of the reactions of a spoiled child. The commonest of these manifestations is resistiveness that may occur when an examination is attempted, feeding is suggested, or a sanitary routine insisted upon. One also meets with resentfulness. One patient, who frequently showed this reaction, explained it retrospectively by saying that she wanted to be left alone. Quite analogous to this is sulkiness that occasionally appears. Then we have, particularly as recovery begins, other childish tricks, such as flippancy in answering questions or the playing of pranks. Such tendencies naturally lead over to frank hypomanic behavior.

Finally, a peculiar characteristic of the stupor apathy must be mentioned. This is its tendency to interruptions, when the patient may return to life, as it were, for a few moments and then relapse. Such episodes occur mainly in milder cases or towards the end of long, deep stupors. It is interesting that the occasion for such reappearance of affect is frequently obvious. We usually observe them in response to some special stimulus, particularly something that seems to revive a normal interest. Visits of relatives are particularly common as such stimuli, in fact recovery can often be traced to the appearance of a husband, mother or daughter. It is also important to recognize that with this revived interest, other clinical changes may be manifest, that the thinking disorder may, for instance, be temporarily lifted. Helen M., for example, when visited by her mother was so far awakened as to take note of her environment, and remembered these visits after recovery like oases in the blank emptiness of her stupor. She further remembered that definite ideas were at such a time in her mind that ordinarily was vacant. She then had delusions of being electrocuted.

In summary, then, we may say that the _sine qua non_ of the stupor reaction is apathy in all gradations, and that this apathy is as distinct a mood change as is elation, sorrow or anxiety. Incidental to this loss of affect there is a dissociation of emotional response whereby isolated expressions of mood appear without the harmonious coöperation of the whole personality which seems to be dead. Thirdly, there tends to be associated with the stupor reaction a tendency to childish behavior. Finally, the apathy and accompanying stupor symptoms may be suddenly and momentarily interrupted. An explanation of these apparently anomalous phenomena will be attempted in the chapter on Psychology of the Stupor Reaction.