Chapter 9

INACTIVITY, NEGATIVISM AND CATALEPSY

1. INACTIVITY. We must now turn our attention to the other cardinal symptoms of the stupor reaction, and quite the most important one of these is the inactivity. It is convenient to include under this heading both the reduction of bodily movement and the diminution or absence of speech. This inactivity is, of course, related to the apathy which we have just been discussing, in fact it is one of the evidences of the loss of emotion. We presume that a patient is apathetic when there is no expression in the face and when he does not respond to external stimuli, whether these be physical or verbal, by movement or by word.

Bodily inactivity is present in all degrees, and in some forty consecutive cases was recognizable in every one. In its most extreme form there is complete flaccidity of all the voluntary muscles, and relaxation of some sphincters. As a result of the latter we see wetting, soiling and drooling. Even those reflexes which are only partially under voluntary control, like those of blinking and swallowing, may be in abeyance; for instance, saliva may collect in the mouth because it is not swallowed, and tube-feeding is frequently necessary on account of the failure of the patient to swallow anything that is put into his mouth. The eyes may remain open for such long periods of time that the conjunctiva and sclera may become quite dry and ulcerate. In these extreme cases there is, of course, no response to verbal commands. What is more striking, no reaction appears to pin pricks, so that it seems as if consciousness of pain were lost.

This deep torpor does not usually persist indefinitely. The commonest evidence of some form of consciousness persisting is probably to be seen in blinking when the eye is threatened or the sclera or cornea actually touched. A very large number of patients, when otherwise quite inactive, showed considerable response in their muscular resistiveness, the phenomena of which will be discussed shortly. The relaxation of the sphincters is apt to persist even after control of the rest of the body is exercised to the point of permitting the patient to stand or walk about.

The first phase of obvious conscious control is seen in those patients who will retain a sitting posture in bed or in a chair. The next stage is reached where the stuporous case can be stood upon his feet but cannot be induced to walk. The next degree is that of walking only when pushed or commanded. Finally spontaneous movement is observed in which the inactivity is evidenced merely by a great slowness.

No correlation can be established between restrictions of speech and motion other than that present in the extremes. With complete inactivity there is almost always consistent mutism, and perfect freedom of speech does not, as a rule, appear until the movements are free. In between these extremes all variations are possible, even the deepest stupors are occasionally interrupted by one or two words; for instance, a patient may remain comatose, as it were, and absolutely mute for six months, then to every one’s surprise say one or two words and relapse into a year of silence. Again one sees cases where movements have become fairly free and yet the patient says nothing. This is another example of that inconsistency in reaction which we have already noted in connection with the mood or affect.

In so far as inactivity is merely an expression of apathy, its causation will be considered in connection with the psychology of the stupor reaction as a whole. In so far as there may be specific factors, however, it may be of interest to consider what information the patients themselves give us from time to time as to what determined their inactivity. It is really surprising how frequently something can be gained either from careful notes taken during the stupor or from the retrospective accounts of the psychotic experiences. Of course when one considers the degree of amnesia which is usually present and the extent of the intellectual defect in general, it becomes obvious that one cannot think of getting anything like a complete explanation of the behavior of any given case. Nevertheless this material is quite suggestive in the mass; it gives one some idea of the mental state as a whole.

Among 40 cases, 27 offered some explanation either during or following the psychosis. Of these, 20 spoke of feeling dead, numb or drugged, or feeling as if paralyzed or having lockjaw. This group, just half of all the cases, apparently ascribed their disability to something which seemed physical. One might call them somatopsychic cases. The other 7 gave more allopsychic explanations: 3 attributed their inactivity to outside influence; 3 more said they were afraid (one of these because she imagined herself to be in prison), which is analogous to the outside influence; the 7th case thought she would injure people if she moved.

The following are some examples of the statements of the somatopsychic group: Laura A.: “I can’t move,” and retrospectively, “My arms were stiff.” Bridget B. claimed retrospectively that she felt dead or drugged, that her limbs were lifeless, she felt as if she had lockjaw. Johanna B. remembered being pricked with a pin on several occasions but claimed that she did not feel the pain at any time. This suggests a definitely hysterical mechanism. Anna L. (Case 16) said retrospectively that she felt as if she were dead, although walking around, and also that she thought she was a ghost and not supposed to speak. Anna M. said she had tried to speak but everything stuck in her throat. Alice R. said that she had no energy, did not want to talk. Meta S. (Case 15) claimed that while stuporous her tongue would not move. Isabella M. in intervals claimed that during the stuporous periods she felt as if dead and said retrospectively when the whole psychosis was over that it was “an effort to speak.” Johanna S. (Case 13), while stuporous when pressed with questions would say: “I can’t think,” “I don’t know,” “I am twisted.” When food was offered her she protested, “I am dead.” Charlotte W. (Case 12), in reviewing her case, said: “I was mesmerized,” “I thought I was dead.” Anna G. (Case 1), in retrospect said: “I don’t think I could speak,” again “I made no effort,” or “I did not care to speak.” Henrietta H. (Case 8) said, “I lost speech.” She claimed that she did not move because she was tired and had a numb feeling. Mary C. (Case 7) said that her tongue had been thick and that she felt dull. Rose Sch. (Case 6) said during the psychosis that her head was upside down and retrospectively that she had been mixed up, could not remember well, did not feel like talking. Mary D. (Case 4) said that she had been dazed, that she had not felt like talking, and that her limbs “were stiff like.” We should probably also include here as a delusion of death the statement of Annie K. (Case 5) who wanted to die and thought she would do so if she kept still enough.

It is rather striking that among all the forty cases only one spoke of being sick--“I am so sick.” Only one evaded questions with “that was my illness.” One would expect a priori that these patients would offer some vague explanations or make complaints of weakness. If these stupors were purely physical in origin, one would expect such explanations as weakness or illness to be offered in accounting for the inactivity. That there is a rather definite type of explanation offered is, we think, distinctly suggestive. If one tries to correlate and group the death ideas, one sees that they are all delusions of death or of loss of energy or complaints of hysterical symptoms that look like sham death. If the lack of energy complained of be looked upon as lifelessness, one can conceive of these explanations being variations of one theme, namely, that of death. In the last chapter it has been shown that a delusion of dying, being dead, or having been dead is extremely frequent in the stupor group. It would seem only natural then to regard the inactivity, in so far as it may be specifically determined, as an expression of some such delusion.

Psychiatrists are more or less aware of there being typical ideational contents in the different manic-depressive psychoses. For instance, every one is familiar with ideas of wickedness and inadequacy in depression, ideas of violence in anxiety, or expansive and erotic fancies in manic states. Quite similarly we have seen that death is a dominant topic in a stupor. Now in addition to these typical ideas we often hear expressed what we might term non-specific delusions, ideas that seem to have nothing to do with a peculiar type of reaction which the patient presents. It is therefore not surprising to find that inactivity is not consistently ascribed to death or a related delusion.

For instance, Henrietta B. had much talk of higher powers that were controlling her, also said that it was fear which kept her quiet. Josephine G. said retrospectively that she had thought she would injure people if she moved and that if she opened her eyes she would murder the people around her. Johanna B. was afraid to talk because she fancied she was in prison. Laura A.: During her stupor was more vague, saying, “I can’t move, they won’t let me be,” without betraying any suggestion of whom “they” might be. Finally Mary C. (Case 7) was still more indefinite, ascribing her immobility merely to fear. When one considers, however, that these five were the only ones who gave any atypical explanation of their inactivity among the thirty-seven cases, the preponderance of the death idea becomes striking.

2. NEGATIVISM. The next of the cardinal symptoms to be considered is negativism. This term, which is often loosely used, we would define as perversity of behavior which seems to express antagonism to the environment or to the wishes of those about the patient. Naturally it is only in the minor stupors that we see it in well-developed form as active opposition and cantankerousness. For example, Harriett C., who stood about until her feet became edematous, would spit out food when it was placed in her mouth but would eat if she were left alone with the food. Josephine G., in a milder state, would turn her back on people. When more inactive once rolled out of bed and lay on the floor. At this time also she tried to keep people out of her room. Rarely, patients may have angry outbursts, as did Annie K. (Case 5) who would strike at the nurses.

Very often the failure to swallow and anomalous habits of excretion seem to be negativistic in their nature. One thinks at once of the necessity for tube-feeding, which is so common even when patients seem otherwise fairly active. Naturally this form of treatment is necessary only when the patient refuses to swallow. Quite frequently a refusal to urinate is met with so that catheterization is necessary, or a patient may never use the toilet when led to it, but will defecate or urinate so soon as he leaves it. These latter, like some other perversities, suggest reactions of a petulant, spoiled child.

By far the commonest manifestation is muscular resistiveness, often spoken of as “resistiveness.” It was present in thirty-two out of thirty-seven of our cases. Usually it takes the form of a contraction of the whole system of voluntary muscles when the patient is touched or the bed approached. Often it appears only when any passive movement of the limb is attempted. All muscles of the limb then stiffen, making the member rigid. Sometimes the negativism is expressed by quite isolated symptoms, such as stiffness in the jaw muscles alone. One patient showed no opposition except by holding her urine for two days. Another kept her eyes constantly directed to the floor. The reaction of another showed no irregularity except for stiffness in the neck and arms and wetting herself once after she had been taken to the toilet. One displayed merely a slight stiffness in her arms. An interesting case was that of Annie G. (Case 1) who kept one leg sticking out of bed. If this were pushed in, she would protrude the other. Mary F. (Case 3) sometimes expressed her antagonism to the environment by slapping other patients. She spoke only twice in a year and a half, and each time it was when interfered with. By far the commonest cause of muscular movement in these inactive cases is resistiveness, and as a rule the inactivity is interrupted only by negativistic symptoms.

If we look for some explanation or correlation of these symptoms, we find that chance references to conduct seem to point in the same direction, namely, to the desire to be left alone. This resentment against interference again reminds us of the reactions of a spoiled child. For instance, Laura A., in manic spells during which she was still constrained and drooled, said, “I don’t want to have my face washed.” In the intervals she showed an intense muscular resistiveness. Mary G. used to say, “Leave me alone,” and covered her head or buried it in the pillows. Maggie H. (Case 14) said in retrospect that she had wanted to be left alone. Similarly Alice R. thought she did not want to talk. Emma K. thought that she was in prison and apparently resented this. Henrietta B. combined in her behavior tendencies both to compliance and opposition. When her arms were raised they retained the new position for a minute. Then she dropped them and said, “Stop mesmerizing me.” But then she put them up again of her own accord, and when she had done this presented intense resistiveness to any movement. Later she extended her arms in front of her and said, “I am all right,” in a theatrical manner, and then added, “Why don’t you go away?”

There seems to be some correlation between inaccessibility and muscular resistiveness. For example, Charlotte W. (Case 12), whose condition varied a great deal, always lost the resistiveness when she became accessible, during which periods she also showed some facial expression. The resistiveness would invariably return when the inaccessibility reappeared. Caroline DeS. (Case 2) lost her resistiveness as she became more accessible, although the inactivity and apathy persisted. This tendency, which is quite common, suggests that muscular resistiveness represents a lower level of expression of opposition which patients put into words or purposeful actions when there is other evidence of some contact with the environment. Sometimes one observes both general resistiveness and specific acts. For instance, Mary G., who said, “Leave me alone,” and covered her head or buried it in the pillows, accompanied her muscular resistiveness with laughter. This shows the affective nature of the apparently purposeless muscular tension. The case of Annie K. (Case 5) is more instructive. In the stage of deeper stupor she had the automatic type of resistiveness but also outbursts of anger, particularly toward the nurses, striking one of them she said, “You are the cause of it all.” When food was offered her, she said, “I wonder people would not leave me alone sometimes.” Again, when her bed was approached, she would clutch and hold the bed clothes in an apparently aimless way as if the impulse to resist never reached its goal. Retrospectively she could not account for her muscular rigidity on the basis of definite ideas, and could recall only that she felt stubborn. In a later period when more accessible, she felt cross and did not want to be bothered. This emotional attitude was quite conscious with her, whereas the acts and speech of the earlier period, when her stupor was more profound, seemed more automatic and impulsive. In other words, the resistiveness looks like a larval attempt to express an idea which is probably not fully conscious and therefore gives the appearance of being aimless. As another example of this we may cite the case of Pearl F. (Case 9), who said when she recovered, “I was stubborn.” In addition to the muscular resistiveness she had shown, she would often bite the bed clothes or scratch herself when she was approached. Mary F. (Case 3), while in a stupor, slapped at nearby patients quite aimlessly. When somewhat better, this conduct appeared in a more conscious form, as sullenness, indifference and smearing of feces (again the behavior of a naughty child). Here one might quote Laura A. once more, whose resistiveness when stuporous was intense but who in her manic spells expressed her negativism in a definite idea, “I don’t want my face washed.”

To summarize, then, we may say that negativism is apparently the result of a desire to be left alone, and that muscular resistiveness is a larval exhibition of the same tendency. But the appearance of this attitude in such aimless, impulsive acts or habits reminds us strongly of the dissociation of affect, which was commented on in the previous chapter. It would seem to be another example of this rather fundamental tendency of the stupor reaction, not merely to diminish conative reactions in general, but to reduce their appearance to that of isolated, partial and therefore rather meaningless expression.

3. CATALEPSY. The last of the cardinal symptoms to be considered is catalepsy. It occurred in thirteen of thirty-seven cases, although it was present only as a tendency in three of these. If we define it as the maintenance of position in which a part of the body is placed regardless of comfort, we can see that sometimes it is difficult to differentiate from the phenomenon of resistiveness with its rigidity. It is most frequently observed in the hands and arms, perhaps because it is, as a rule, most convenient to demonstrate the retention of awkward positions in the upward extremities. But any part or even the whole body may be involved; for example, Charles O. retained standing positions even where balance was difficult. This phenomenon is often accompanied by “waxy flexibility,” where the joints move stiffly but retain whatever bend is given them, like a doll with stiff joints.

The significance of catalepsy is best studied by considering its relationship to other symptoms and by noting remarks made by the patients in reference to it. The most important observations which we have made seem to indicate that it never occurs with that degree of deep inactivity which suggests a complete lack of mentation on the part of the patient. One is therefore forced to conclude that back of this phenomenon there must be some purpose, some kind of an ideational content, although this may be of a primitive order. This is demonstrably true in some cases, at least such as that of Isabella M., who left her arm sticking up in the air but took it down to scratch herself and then put it back. Somewhat similarly, Charlotte W. (Case 12), when she was shown during convalescence a photograph of herself in a cataleptic state, said that that was when she was waiting to go to Heaven and was afraid to move. Again she remarked, “I was mesmerized.” Josephine G., who showed only a tendency to catalepsy, said that she feared the devil would get control of those about her if she moved. Sometimes there is a development of this symptom from others which seem to be ideational in their origin. For instance, Charles O. began making flail-like movements. These passed over into slow circular motions which finally subsided into the maintenance of fixed position.

References to hypnotism are not infrequent, and in many cases there is evidence of a delusion that the posture is desired by those in charge of the patient. Annie G. (Case 1) said so directly. In retrospect she explained the holding of her arms in the air by saying, “I thought you wanted me to have them up.” Henrietta B. at one examination kept her arms raised in the position in which they had been put for a minute and then dropped them, saying, “Stop mesmerizing me.” But she then put them up again of her own accord and now presented intense resistance to any motion. Later she extended her arms in front of her and said, “I am all right,” in a theatrical manner. Some patients give evidence in other symptoms of larval efforts at coöperation with the actual or supposed wishes of the physician and in such cases it is not impossible that passive movements are interpreted as orders. One must remember in this connection that the more primitive are the mental operations of any individual, the more important do signs, rather than speech, come to be a medium of communication with other people. As an example of this type we might mention Rose Sch. (Case 6), who flinched from pin pricks (showing that she felt them) but made no effort to get away. When somewhat clearer she said that she was “here to be cured.” Similarly Mary D. (Case 4), who showed no catalepsy from ordinary tests, kept her head off the pillow for a long time after it was raised to have her hair dressed. She showed such perseveration in many constrained positions. She too flinched from pin pricks but not only made no effort to prevent them but would even stick out her tongue to have a pin stuck in it.

The relationship of catalepsy to resistiveness is interesting but unfortunately complicated and unclear. In only one of our cases was catalepsy definitely present without resistiveness, and in one other a “tendency to catalepsy” was noted without muscular rigidity being observed. In this latter case, when the catalepsy became unquestionable, resistiveness also appeared. It is one thing to note this coexistence and another to explain it adequately. All that we can offer are mere speculations as to the real meaning of the association of these phenomena. It may be that the tension of muscles that occurs when resistiveness is present gives the idea to the patient of holding the position. There would be two possible explanations for this. We might think there is a dissociation of consciousness, like that of hysteria, where the feeling of tenseness in the muscles that comes from the resistance to gravity is not discriminated from the resistance to the movements made by the examiner. On the other hand, there might be a similar dissociation where the perception of contraction in the antagonistic muscles is interpreted as the action of the examiner in placing the limb in a given position. This latter view would seem, on the face of it, ridiculous, inasmuch as its presumes the existence of two directly opposed tendencies, namely, those of opposition to the will of the physician and compliance with it. But ambivalent tendencies are frequently present in psychopathic states, and moreover we find occasionally some evidence in the behavior of the patient to substantiate this view. For example, at one stage of the stupor of Annie G. (Case 1), her arm could be moved without resistance. Then the elbow would catch and at this moment the position would be maintained. Such observation is highly suggestive of the resistance being signal for the catalepsy. In Isabella M. the catalepsy appeared when resistance to passive movements also developed. On the other hand, when the resistance became extreme, the catalepsy was reduced, and vice versa. This makes one think of two tendencies: suggestibility on the one hand, and opposition on the other. We might presume that when both are present and equally strong, stiffness with passive movements results as a kind of compromise, but when there is a greater development of one, the other is inhibited.

Such speculations remind one strongly of the psychology of conversion hysteria and of hypnotism. In some cases of stupor hysterical symptoms are quite definitely present. For instance, Celia G. began her psychosis with hysterical convulsions which would terminate with short periods of stupor. Later the stupor became persistent and during this stage she had catalepsy (and restiveness as well) in her left arm only. On recovery from her stupor she complained of stiffness in her hands, which examination proved to be a purely hysterical difficulty.

This whole subject is without question obscure and many more and very careful observations are needed before really satisfactory explanations can be given for these phenomena. That it is a reaction which is related to the primitiveness of the mental content and the intellectual deficit in stupor would seem to be a reasonable view, inasmuch as quite similar phenomena have been observed in a large number of animals, even among crustaceans. As a result of our own observations the only thing we feel at liberty to state with real confidence is that catalepsy is presumably a phenomenon mental in origin rather than somatic, because it always occurs in conditions which show other evidence of mentation.

Whatever may be the origin of the idea of the posture assumed, there can be little doubt that its indefinite maintenance is a phenomenon of perseveration. The conception of the position being in the patient’s mind, it is easier to hold it than elaborate another idea. This, of course, is part of the intellectual disorder in stupor. In fact, it is difficult to imagine any one whose critical faculty was functioning coöperating in a test for catalepsy.