Forms of Dementia Praecox

But above all, as Bleuler especially has shown in detail, the patients lose in a most striking way the faculty of logical ordering of their trains of thought. On the one hand, the most self-evident and familiar associations with the given ideas are absent. It seems as if these were only partially illumined, and therefore were not in a position to call into consciousness thoughts that lie quite near. On the other hand again, the most unnatural combinations of heterogeneous ideas are formed, because their incongruity is not perceived on account of some purely external relation, as similarity in sound, or coincidence in time. The most evident truths are not recognised, the greatest contradictions are thoughtlessly accepted. A patient asked the doctor:

Is your name Julia?

Another called the physician:

Mrs Colonel.

By these disorders, which in many respects remind one of thinking in a dream, the patients’ mental associations often have that peculiarly bewildering incomprehensibility, which distinguishes them from other forms of confusion. It constitutes the essential foundation of incoherence of thought.

In less severe cases this is shown only in increased facility of distraction and increased desultoriness, in passing without any connection from one subject to another, in the interweaving of superfluous phrases and incidental thoughts. Similarly, Pfersdorff found in continuous reading a tendency to make meaningless mistakes, to perseveration of certain words, to changes and omissions, even when single words or short sentences were correctly rendered; he concludes rightly that there is a failure of attention. A patient who was quite sensible, when asked to copy the fable of the “greedy dog,” performed the exercise correctly as far as the sentence: “But when he snapped at it, his own piece of meat fell from his mouth, and sank in the water,” then, however, continued:—

And as now her present condition depends wholly on what Dr J. M. plans for the future, who wishes to make himself acquainted with what is in connection with it, and of whose condition she wished to be again acquainted with, which he wished on his own desire. Now he had nothing at all but what was yours, which seems to lose what was his, but he himself tried to lose it, the fortune which for him was trying to be acquired,” and so on.

The line of thought here leaves the appointed exercise and moves in indistinct spheres of ideas, which otherwise occupied the patient, and then, without any connection, again brings in parts of the fable (“Now he had nothing at all,” “Who wants to take the goods of others loses his own”). Still more striking is the departure from the given idea in the answer of a patient who was asked what year it was:—

O I know nothing, what shall I say? Fire, fire! O you old beast, devil, wretch, dog, slaughtered, slaughtered! It’s cold in the wood; hurrah! Damn it a million times, beast of a cat, slaughtered!

In certain circumstances the incoherence may go on to complete loss of connection and to confusion. An example of this is given in the following answer of a patient to the question: Are you ill?—

You see as soon as the skull is smashed and one still has flowers (laughs) with difficulty, so it will not leak out constantly. I have a sort of silver bullet which held me by my leg, that one cannot jump in, where one wants, and that ends beautifully like the stars. Former service, then she puts it on her head and will soon be respectable, I say, O God, but one must have eyes. Seats himself and eats it. Quite excited, I was quite beside myself and say that therefore there should be meanness and there is a merry growth over. It was the stars. I, and that is also so curious, the nun consequently did not know me any more, I should come from M. because something always happens, a broken leg or something, they’ve had a quarrel with each another, the clergyman and she; a leg has just been broken. I believe it is caused by this that such a misfortune happens, such a reparation for damages. I have also said I shall then come in the end last, with the sun and the moon, and too much excitement, and all that makes still a great deal of trouble. Kings do not collect the money, in this way the letters have been taken away from me, as I at last specially think from the that, and all are burned. You can imagine that comes always from one to the other.

In a few places here, a certain connection between the ideas can perhaps be recognised:—“ill—skull smashed,” “held by my leg—not jump in,” “something happens—broken leg,” “misfortune—reparation for damages,” “excitement—trouble,” “letters taken away—burned,” “excited—quite beside myself.” Also “silver bullet” and “stars,” and further on “sun and moon” and “nun” and “clergyman,” who “have had a quarrel with each other,” point to associations of thought. On the whole, however, we have before us a completely unintelligible and aimless series of words and fragments of thoughts. It must certainly be taken into consideration that the actual train of thought is possibly much less disordered than the expression of it in speech, because the patients, as indeed happened in this case, can in certain circumstances not only perceive correctly, but also further elaborate what they perceive and behave fairly rationally.

Stereotypy

We almost always meet in the train of thought of the patients indications of “stereotypy,” of the persistence of single ideas. If the patient continues talking, the same ideas and expressions usually turn up again from time to time. Occasionally the persistence gets the mastery of the train of thought to such an extent that the patients for weeks and months always move in the same monotonous sphere of ideas, and cannot be brought out of it by any means.

Evasion

Further peculiar disorders of the train of thought which here and there are observed, are evasion and a feature which Bleuler more accurately characterised as “intellectual negativism.” Evasion or paralogia consists in this, that the idea which is next in the chain of thought is suppressed and replaced by another which is related to it. It appears most distinctly in the patients’ answers to questions; but it might be possible that the complaints of the patients that their thoughts are “drawn off” from them, “distorted,” refer to similar occurrences. An example is given in the following answers of a patient to the physician’s questions:—

What is the name of this gentleman? (Dr A.):

Little man.

What is his name?

Floischütz (The name of a fellow patient).

How many fingers am I holding up? (3)

Four.

How many now? (4)

Five.

And now? (2)

One.

How much money is that? (three pennies)

Sixpence.

No, you know quite well:

Twopence.

No, how much?

Fourpence.

Now name the number that was left out, how much then?

Twenty-five thousand.

What do you mean by twenty-five thousand?

That I’m all right.

It is here easily seen that the patient deliberately avoids the right answer which he certainly has at his command, a proceeding which at first makes the impression of intentional dissimulation. A patient replied to the question how old she was:

One day.

Clearly this phenomenon is nearly related to the negativistic disorders of thought. They appear in the difficulty to carry on a series of ideas as one wishes, the patient’s thoughts are “taken” from him. So it sometimes comes to pass that he is obliged to think the opposite of what he really wishes. There are “quarrels in his head.” One patient said:

My ideas have quarrelled,

while another, perhaps with reference to such occurrences, said:

Swindling is constantly going on in my inside.

This state appears more clearly in the utterances of other patients, that they “are forced to think otherwise,” that they “have to think the opposite of what other people with normal understanding do.”

Constraint of Thought

From these and similar experiences the feeling which has already been discussed often develops in the patients, that their thinking is constrained, has been withdrawn from the dominion of their will by irresistible influences. On the one hand thoughts arise in them which they feel as strange, as not belonging to themselves; there is a “thronging of thoughts,” a “pushing of thoughts,” sometimes in tempestuous form. A patient had to “drive through his brain in four hours nineteen years”; another thought he would have to write a book if he were to note down everything that came into his head. But on the other hand the patients cannot think as they wish; their thoughts are withdrawn from them, slip away from them, although they exert themselves to hold them fast and to think them out. Owing to this there can be a sudden “blocking” of their thought, producing a painful interruption in a series of ideas.

They never tire of describing this constraint of theirs in ever varying ways. The patient’s thoughts are influenced, inspired, pressed on him; he must receive them like a telephone; they are forced on him by hypnotism and suggestion, act on him “by suggestion.” Everything that he thinks or says is thought or said under compulsion. A patient had always to fight against the idea that he was Christ. Reading is interrupted by thoughts and explanations; thoughts are arrested, blurred, the patient has to exert himself to squeeze them out; he must think what people say. He feels as if his brain stood still, as if he had two brains. He is no longer himself, he has a kind of double consciousness; the voices pull a thread, so that he has to think such stupid things. The thoughts can be taken out of people’s brains; the patient is confused in his head, he cannot grasp any clear ideas, he cannot bring order into the jumble of his thoughts, there is an “entanglement in his mind.” A patient wanted to strangle herself because she had not her thoughts any longer. Thoughts are made by others in the distance, in Berlin, read off, taken away, carried over. A patient said:

It was blown into me that way.

His thoughts escape from the patient, he cannot catch them up, he is no longer independent. A patient “had to speak about politics,” another had always to think of “business arrangements,” a third “had to despise people.” Frequently, as before described in detail, the powers which carry out such thought-influences, take on the form of voices which take away, turn aside, or suggest thoughts.

Mental efficiency is always diminished to a considerable extent. The patients are distracted, inattentive, tired, dull, do not take pleasure in work, their mind wanders, they lose the connection, they “cannot keep the thought in mind,” they have no perseverance. It is true they are often able to carry out quickly and correctly tasks depending solely on memory or practice, sums, repetition of what they have previously learned, but fail completely as soon as it is a matter of psychical activity requiring mental effort. In work the patients soon become negligent, they get bad certificates, pass no examinations, are turned off everywhere as useless, and easily fall into the condition of beggars and vagabonds. They sit about idle and the most they do is to turn over the pages of an old calendar or to stare at the advertisements in a newspaper. Others develop great diligence, “study all night long,” but accomplish nothing at all, take up trifling or aimless occupations, begin to compose bombastic, incomprehensible rhymes, to copy a foreign dictionary, or they lock themselves up in order to learn poems off by heart.

Experiments in calculation yield further insight into the changes in mental efficiency. These experiments were employed in a number of patients according to the procedure formerly employed for alcoholics. Fig. 1. Calculation tests in Dementia Praecox.

Here the work done in the first five minutes and in the second five minutes, on the days when no pause was made, is represented by a continuous line; the value of the second five minutes, on the days when a pause was made, by a broken line, while the average work done in the first minute is put down at a hundred. We recognize in the first place that the values in the first part of the experiment sink very much more quickly than in the directly comparable normal attempts, a behaviour, that may be caused either by specially great liability to fatigue or through very rapid yielding of the original will-tension. The striking oscillations of the values of the average minutes particularly in the second part of the curve as also the high values attained even here in single minutes (sixth and tenth) is in some measure contrary to the assumption of unusually great effect of fatigue. It is still more decidedly disproved by the insignificance of the general effect of the pause which we know may be regarded within certain limits as the measure of fatigue. The work performed rises considerably, it is true, in the sixth minute on the days when there was a pause, but sinks again immediately and keeps after that within the limits of the values reached on the days when there was no pause. Comparison with the curves of normal persons and still more with those of the very easily fatigued alcoholics shows quite distinctly the difference in the effect of the pause. The even and rapid fall of the values in the first beginning of the task, as well as immediately after the pause, points here also to a very rapid yielding of will-tension, as in alcoholics, but it is not connected with heightened liability to fatigue, but with the direct and very considerable oscillations of the work done, which clearly correspond accurately to the oscillations of attention observed by Busch and Gregor which also usually appear in the clinical picture.

Judgment

Further the faculty of judgment in the patient suffers without exception severe injury. What always surprises the observer anew is the quiet complacency with which the most nonsensical ideas can be uttered by them and the most incomprehensible actions carried out. It is true that they often move with tolerable certainty in accustomed paths, but in the psychic elaboration of new experiences, in the judgment of circumstances not hitherto experienced, and in particular of their own state, in the drawing of obvious conclusions, in the bringing forward and trial of objections, they not infrequently commit the grossest blunders. One has the impression that the patients are not in a position to accomplish that mental grouping of ideas which is requisite for their survey and comparison, their subordination among one another and for the discovery of contradictions. In this respect they resemble dreamers in whom likewise the ability to sift the ideas which come into the mind, to arrange them and to correct them according to the standards gained by former experiences and general ideas is abolished. These disorders, on whose great fundamental significance Bleuler also lays most emphatic stress, suggest an encroachment on the inner action of will.

The patients often have a distinct feeling of the profound change which has taken place in them. They complain that they are “dark in the head,” not free, often in confusion, no longer clear, and that they have “cloud thoughts.” They cannot grasp a thought, cannot understand anything; their mind is scattered; their thoughts have flowed away; their brain is no longer competent, is enfeebled. A patient said:

My thoughts went away and will never come back.

Another:

My mind has been taken away by spiritual influence of speech and will.

Others expressed similar concerns: “My whole mental power has disappeared, I have sunk intellectually below the level of a beast,” “I am quite out of my mind,” “I am being punished a little by my imagination,” “I have become very stupid lately,” “I’ve got something in my head,” “My mind sometimes goes away,” “The stupid fellow is confused.” Others call themselves “Half-fools,” “easily weak-minded,” “idiotic”; they are afraid they are going out of their mind, becoming insane, falling ill of softening of the brain. A patient said:

Things go round about inside me, thoughts which belong to a sanatorium.

Another said that he had lost the faculty of perception and energy, that he was wholly changed. A patient declared she was quite well, but stupid, and would like to be cured, while another begged that she might be freed from spirits:

I did not wish to be mad, to be the plaything of other people, but wished to be like other human beings. I couldn’t stand it any longer; I was quite incurable.

Many patients begin to read medical books, connect their complaint with onanism, begin all sorts of cures. A patient was absorbed in the books; “How Can I Become Energetic?” and “Guide to an Imposing Appearance,” and he diligently carried on medical gymnastics, deliberately gazing at the sun as long as possible every day in order by so doing to improve his health. In contrast to these indications which sometimes characterize the situation with surprising clearness, understanding of the disease disappears fairly rapidly as the disease progresses in an overwhelming majority of cases even where in the beginning it was more or less clearly present.

Delusions

Neither transitory nor permanent, are developed with extraordinary frequency on the foundation of the morbid change which is created by dementia praecox. In the first period of the disease they are usually by preference of a sad character, hypochondriacal, or ideas of sin or of persecution. The feeling of disease takes on insane forms; the brain is burned, shrunken, as if completely gone to jelly, full of water, the mind is “drawn like rags from the brain”; the patient “has only a little knuckle of brain left”; the nerves are teased out. The tongue is made of iron, the lungs are dried up, blood is in the spinal marrow, w