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Dementia Precox

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DEMENTIA PRECOX, a term used in psychiatry to designate a disorder group char acterized by certain types of mental deteriora tion or disintegration. This term originated with Kraepelin, professor of psychiatry at Munich. Clouston of Scotland termed the dis otder the. "insanity of siirileseenbe,"and Zia'ler of Zurich has used the term "schizophrenia? Thus from the terms alone a brief description can be formulated— a mental disorder, chiefly occurring in adolescence or young life, char acterized by a splitting of the psyche "schizo phrenia,* and usually leading to a precocious dementia, or mental breakdown. This mental disorder is the most frequent of all of the psychoses, constituting fully 30 per cent of the admissions to hospitals for mental diseases. In some individuals it runs a comparatively mild course recovers, • or becomes chronic, this last individual being called "eccentric," "bizarre" or "very peculiar? ' On the other hand it may run an exceeding violent and furious course — the patient being wildly maniacal, with active delirium accompanied by hallucinations. These patients may die in a delirium from exhaustion or they recover — or the process quieting down leads to a more chronic mild deteriorating proc ess, marked by episodes or outbursts of unruly or disorderly conduct. These types of chronic de mentia precox cases make up the vast majority of the mentally ill in the State hospitals for the insane of the country. The chief feature that characterizes dementia precox is the tendency for the patient to make use of autistic think ing. That is the individual withdraws his interest from the external world [introverts] and constructs a phantasy world into which he tends to withdraw more and more. At first this type of thinking detaches him only partially from the world of reality. He is able to come out of his ((day dreaming)) as it were —but as the introversion of his phantasy life becomes more and more pronounced the splitting between his phantasy world and the real world becomes too great to be bridged. When this occurs the individual is "sick." The early stages of this process are marked by a lack of interest taken by the potential schizophrenic in his surround ings. He is apt to lie in bed all the morning or all day, uninterested or only mildly inter ested in the newspapers or books. He fails to move about or does so in a listless halfhearted manner. There is a failure of voluntary at tention and a lack of sociability. There may be some keenness of interest but it is largely on the internal phantasies. Hence they seem heedless of what is going on about them, may lose themselves in their abstractions, may wander about aimlessly. In this stage many take up a tramp or hobo existence and are able to get along in this haphazard, indifferent, lazy sort of manner, without many obligations and living from hand to mouth. In others there is a greater disintegration — the lack of unity of the personality commences to show in the development of certain trends which have been called the [a] hebephrenic, [b] catatonic and [c] paranoid types of the disease process. [a] The hebephrenic types show a gradual dilapida tion of interests. They make up the simpler types the disease. They show a number of tional somatic or bodily signs. Headaches are frequent, irritability and failure of concen tration,' with gastrointestinal disturbances, are prominent. They sleep badly and in this phase are often diagnosed by the unskilled physician as subjects of "nervousness," or "neurasthenia) or "nervous breakdown? Some are mistakenly treated for "stomach trouble," or other bodily disease until the mental disorder passes into a further stage of evolution. These patients then are apt to develop "flurries? They be come excited, confused, congested. They do not sleep, cannot work, go aimlessly here or there, become fussy, possibly go on a "tear"— get intoxicated, create a disturbance, commit some moral infraction or sexual delinquency and land in the police station or hospital where the mental nature of the difficulty may be ap parent. All may have been in the making a Month, a year or two — each individual case varying greatly. Depression or silly conduct may mark the gradual development of these breakdowns. The ideas which some express become more and more bizarre. They fre quently hear voices —are having telepathic coin munications. Some of these patients believe themselves clairvoyants, can read the stars, or what people are thinking. The train of thought commences to get loose, they commence to be come foolish or fantastic in their ,speech. They repeat things over and over again. They nearly all become resistant and negativistic— they are all "from Missouri" One offers to shake hands, they pull back. "Show the tongue I", as a re quest of the doctor, is met with shut teeth. If they talk much they later tend to develop a gibberish all of their own. A "word salad° is a type of this which consists of a regular hash of different ideas, all of which may be ex pressed in the most matter of fact and ap parently sensible manner. The patient acts as if it were quite logical. These simple demented and hebephrenic types go on to delusional ex pressions of a most bizarre type. These de lusional ideas are often based upon the halluci natory voices or feelings. These are all in ternal wishes—their own phantasy formations— but which are referred to their organic sensa tions or to.the external world. They project their wishes upon the body or externally upon people. Thus a strong desire to masturbate will be in terpreted as some one else putting the X-ray upon the genitals. Other types of misinterpre tation are frequent. These hebephrenic types gradually get more and more involved in them selves and finally are found in institutions sitting about the wards, muttering to themselves, or monotonously walking up and down, grimacing or gesturing or making some bizarre series of movements. They are unapproachable, their detached personality is inaccessible to ordinary modes of contact and they live a life apart from the rest of the world. They carry out the idea of the old Greek philosopher, Protagoras, who said "It is only when we do not act at all we can differ utterly from all others and live our own private life apart." These patients have separated themselves froni the social herd and live in their own phantasies. From the ex ternal point of view, and from the standpoint logical thinking, their productions are meaningless and "crazy? but if one can get within the wall of their phantasy life, one can learn that from the ego point of view their system is quite logical. It is like a foreign lan guage they use which if the key be found, the thought life of thesepatients can be interpreted and may be adjusted to reality—especially if they are studied before the fragmentation of the personality has gone too far. [b] In the catatonic types the symptoms just described are also found—but in addition there is a greater amount of motor activity., The muscles are more . tense. The patients hold themselves stiffly. They stick out their chests, or hike a shoulder, or constantly show unique or queer mannerisms. Some will stand in one position for hours, days or even weeks. Some patients are known to lie rigid in bed for years, not moving— stomach tube fed, mute and abso lutely resistant and with eyes closed, oblivious to everything. heat or cold, hot irons or ice, no amount of torture can make them move. In the days of the mediaeval tests for witches or devils some of these patients stood most sur prising tortures without flinching. They will say the same thing over and over again — °Locks and keys — keys and locks — locks and keys — keys and locks° one patient will repeat six to seven hours without cessation. Some walk backward and forward a certain invariable number of steps — °Stereotypy?) Again the catatonic type of patient will become violently excited, rush aimlessly here and there, into things, through windows, pound on doors, or attack people with chairs or sticks with enor mous violence. This fury may be frightful, occasion a high temperature and a host of physi cal symptoms, or the patient will go into a stupor and lie comatose for weeks or months — abso lutely negativistic to every call of nature, refuse to empty their bladders or move the bowels. Saliva may accumulate in the mouth and even decompose without their regard. In a few cases, after it may be months of stupor, these catatonics will suddenly get up, appear per fectly normal and, surprising as it may appear, may know everything that happened about them for months, during which time they lay ap parently oblivious to their surroundings. More

often, however, they pass into a chronic stage of dementia or die from an acute meningeal suf fusion —°Catatonic brain . [c] The paranoid forms seem to come off the best in their conflicts. They split the least as it were. They construct a fairly logical system of de fense. They find an external cause for their internal wishes and by this projection mechan ism are able to get along fairly well in the social world. Only when they commence to react violently to these external sources of irritation are they made the subjects of detention, of in carceration. A large number of mild types are to be expected. Many inventors, reformers, re ligious zealots, quacks, litigious and vindictive individuals approach this group or slide into it in varying degrees. Most frequently the delu sional attitudes are sexually colored. The most common is that certain men or women are fol lowing them or conspiring against them to ruin them, or degrade them. Various secret so cieties are banded against them. Cliques and political parties are hampering their activities. Certain of these patients are constantly seeking vindication for certain fancied wrongs. Their reputations are being assailed and they must protect them. Others must right all the wrongs of others, especially political wrongs and hence become assassins or regicides, etc. Others are religious fanatics and would make what is symbolic, real. To take the blood of the °Savior,* in a symbolic sense, is not sufficient. They must have actual blood and hence kill to satisfy their pathological sadistic wishes. Cer tain sadists and masochists belong in this para noidof dementia precox. These are often remarkable for their apparent lucidity of and clear logical capacities. In the paranoid type the fragmentation of the person ality is the least marked and hence there is a greater coherency of the personality. Thus many of this type of mentally disordered indi viduals are rarely recognized by the layman to be sick. They are often thought of as difficult People to get along with, especially in the family circle, but to the average outsider they are rarely considered sick. They may even occupy important positions in the community and yet be very seriously and severely sick. Under the term a number of this type were classed by former students of mental disorders. • Nature of Dementia From this abbreviated description it may be pointed out that it presents correlations on the one hand to the more distinctly so-called psychogenic types of disorders, such as the psychoneuroses, and. on the other hand to many of the more distinctly somatic diseases, (various chronic disorders). It is possible to formulate the mental symptoms in a way that they are formulated in the psycho neuroses. The mental symptoms are capable of interpretation at a psychological level. On the other hand, it can be seen that recent in vestigations are tending to show more and more that there are distinct biochemical disturbances during life and pathological changes are being found after death. In any case the acute cases that lead to death must be conceived as having profound bodily changes correlated with psychi cal symptoms. The formulation of the disease process from either standpoint alone must of necessity be unsatisfactory. For example, the toxic theory of the etiology fails to give a comprehensive idea of why the mental mani festations take the particular form they do, why for example, an hallucinatory voice which a patient heard should be that of a young woman whom the patient had seduced, °telling him to lead a decent life, This is the patient's self-critique appearing in hallucinatory form. It would seem, that when the type of splitting of the personality is very severe then the term dementia precox or schizophrenia applies. It is possible that the somatic processes, whatever they may be, aid in this deeper regression to the infantile and the archaic in the individual and therefore have been less efficiently sub limated and thus permit the older phylo genetic thought symbols to appear in conduct. At any rate, it seems quite evident that the greater difficulty of conception here is due in part to the quite arbitrary separation of the individual into two distinct and mutually ex clusive parts, namely mind and body. The dualistic hypothesis that conceives of the mental and the physical going side by side without mutual interference or interaction is responsible for sueh a conception. From the medical stand point such a concept seems entirely unnecessary, for one is met at every turn with the intimate relations constantly maintained between the body and the mind, and therefore comes natur ally to consider the human being as a biological unit presenting types of reactions that at one extreme are predominantly psychic, while at the other they are predominantly physical, but which present every grade of intermediary type. The severe mental disturbance of the nature of anxiety that goes with certain cardiac and pul monary diseases is well known, as are also the physical upsets, particularly the testinal, that are associated with certain mental conditions such as worry. The interrelations between the mental and the physical are a matter of daily observation. Occasionally, however, they are very pronouncedly empha sized. The following case, cited by Jelliffe and White, is an instance. •A chronic patient who had been for many years in a hospital, working daily at outdoor labor, was suddenly seized with a violent impulse in which he attacked all about him. He seized a heavy iron bar, killed two people and injured another, and ran head long and wildly without direction into the woods. He was finally cornered, and in the process of securing him he was shot by a farmer with a load of buckshot, none of which, however, penetrated farther than through the skin and produced no serious wounds. He was brought back to the hospital, incoherent, mumbling and trembling, showing all the evidences of a tremendous emotional upset. The shot were picked out of his skin, the wounds were dressed and he was put in bed. Up to that time he had been a strong, physically healthy negro. He never left his bed again, and approximately a year afterward he died, having developed an acute tuberculosis. Such cases as these demonstrate the necessity of considering the human being as a unit and not endeavoring to draw hard-and-fast lines of distinction between the mind on the one hand and the body on the other.* In the pres ent state of knowledge, however, one is often unable to make any specific correlation be tween the physical findings and the mental symptoms, while on the other hand it is quite possible to express the symptomatology of the disease, to describe it, to, so to speak, recon struct the psychosis purely in psychological terms. For the present, therefore, the disease must be described psychologically, and the ex planation of the mental symptoms must be sought psychogenetically, without, however, forgetting that there are certain somatic changes which are pretty generally attached to the symptomatology of the disease process and which must ultimately be made to fit into the general rubric before a complete understanding of the entire situation is had. On the psycho logical side, then, dementia ptecox is seen to be a certain type of reaction to a mental con flict, resulting in a splitting of the psyche and the outcrop of unconscious mental trends to the surface of the mental life. The patient is confronted with a situation to which he can not quite adjust himself which is absolutely in acceptable and impossible, and he is therefore driven away by his incapacity to assimilate it and cast back upon himself. The battle of the opposing forces produces the disease picture which is the outward evidence of the effort on the part of the individual to reach a solution of the difficulty. The symptoms are the result of the appearance of the unconscious trends distorted and disguised as they are in dream formations. Jung has especially noted this similarity to the dream state and would con sider dementia precox as a sort of waking dream or dream from which the patient does not awake, the dream picture being fixed as it were.

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