Diagnostic Considerations

CHAPTER VI. COURSE AND REMISSIONS

The general course of dementia praecox is very variable. On the one hand there are cases which very slowly and insidiously bring about a change in the personality, outwardly not specially striking but nevertheless very profound. On the other hand the malady may without noticeable prodromata suddenly break out, and already within a few weeks or months give rise to a serious and incurable psychic decline. In the majority of cases with a distinctly marked commencement a certain terminal state with unmistakable symptoms of weak-mindedness is usually reached at latest in the course of about two to three years. One must always be prepared for acute exacerbations of the disease leading to a lasting aggravation of the whole condition. Not altogether infrequently the true significance of a change in the personality lasting for decades is first cleared up, by the unexpected appearance of more violent morbid phenomena, in the sense of dementia praecox.

The fact is of great significance that the course of the disease, as we have seen, is frequently interrupted by more or less complete remissions of the morbid phenomena; the duration of these may amount to a few days or weeks, but also to years and even decades, and then give way to a fresh exacerbation with terminal dementia. Evensen saw a patient have a relapse after thirty-three years. Pfersdorff established improvement for the duration of two to ten years twenty-three times in one hundred and fifty cases (15 per cent.); I myself found real improvement in 26 per cent. of my cases, when that of the duration of a few months was also taken into account. It has been already mentioned that such improvement is to be expected most frequently in the forms which begin with excitement, and is almost entirely absent in paranoid forms of the disease as also in simple silly dementia; one is reminded here of similar experiences in paralysis, in which the expansive forms also exhibit frequent and considerable improvement while demented paralysis rarely does and, if it does, the improvement is only slight. Among women improvement seems to be rather more frequent than among men.

The Beginning of Improvement

The improvement takes place as a rule very gradually. The excited patients become quiet; the stuporous more accessible and less constrained; delusions and hallucinations become less vivid; the need for occupation and for the taking up again of former relationships becomes active. At the same time sleep, appetite, and body-weight usually improve considerably. But astonishing improvement may appear quite suddenly; it then for the most part certainly does not last long. We find the patient, who up till then appeared to be quite confused in his aimless activity or his hopeless degradation, all at once quiet and reasonable in every way. He knows time and place and the people round about him, remembers all that has happened, even his own nonsensical actions, admits that he is ill, writes a connected and sensible letter to his relatives. It is true that a certain constraint of manner, a peculiarly exalted or embarrassed mood and a lack of a really clear understanding of the morbid phenomena as a whole will always be found on more accurate examination.

Degree of Improvement

The improvement reached is very different in individual cases. Among those here worked up by myself there were 127 patients who ultimately became demented, in whom such a degree of improvement occurred, that a return to home life was possible; in eight further cases which exhibited a periodic course, such improvement occurred even very frequently. In these latter cases, however, there existed in the intervals a distinct psychic weakness gradually increasing, which for the most part bore the stamp of simple emotional dulness and great poverty of thought, but was occasionally accompanied by slight, cheerful excitement, also perhaps by isolated hallucinations and delusions. That there was a state of even approximate health in the intervals was, however, quite out of the question.

Duration

Leaving these peculiar instances out of account, cases of improvement may be grouped according to their duration in the following way, if in the few patients whose state improved several times we consider only the longest period of such improvement:

No. of years	1	2	3	4	5	6	7	8	9	10	12	13	14	15	16	29
No. of cases with periods of improvement	2	2	9	4	4	4	6	3	2	5	3	1	2	2	1	1

In the great majority of cases therefore the periods of improvement do not last longer than three years. Among those here noted it was stated sixteen times without reservation that the patients had been completely well. The duration amounted in 3 cases to one year, in 2 to two years, in 4 to three years, in 2 to five years, in 2 to six years, and 1 to four, 1 to seven, and 1 to twenty-nine years. In seven further cases the patients were described as “quiet,” “orderly,” “not attracting attention,” and were at least in a position to earn their own living again without difficulty; it was a case here of periods of improvement lasting two to three years, 1 of four years, and 1 of twelve years. There were also two cases in which the patients were described as well, but talkative and irritable; in one of these cases, in which already two periods of improvement of several years’ duration had preceded, the relapse leading to terminal dementia only occurred after fifteen years. In thirty cases the patients took up their work again as before, but appeared quiet and depressed, or timid and anxious, possibly also at times excited. One of these patients passed an examination well in the interval which lasted nearly three years. The duration of the improvement fluctuated for the most part between one and ten years; it amounted in about half of the cases to over two years; among these there were cases each of seven, eight, nine, ten, thirteen, and sixteen years.

In twenty-six further cases there was to be noted an essential improvement of the condition but without the complete disappearance of all morbid phenomena; here there were usually fairly short intervals which in half of the cases lasted less than two years. There were also ten cases in which after the disappearance of the more striking morbid symptoms there remained a distinct degree of psychic weakness, especially emotional dulness and lack of judgment; in seven of these cases the improvement did not exceed three years. In a group of thirteen cases there remained marked restlessness and irritability with a tendency to passing states of excitement; the duration of this state, till a fresh outbreak occurred, amounted nine times to over three years, five times to ten years and over. Perhaps there might be added here five cases, in which the patients during the period of improvement led a restless life and became vagrants; in only one of these did the relapse follow in less than three years.

In the cases which still remain, from which ten must be deducted, about which no sufficient information was forthcoming, the morbid phenomena were even in the intervals still more severe. Some of these patients were indeed quiet, but wholly unoccupied and stayed a great deal in bed; others still gave utterance to delusions or suffered from hallucinations; strictly they ought not to be counted with those who had periods of essential improvement at all. Leaving them aside, we come to the conclusion, that 12-6 per cent. of the improvements bore the stamp of complete recovery, which, however, only seldom lasted longer than three to six years. Among all the cases ultimately leading to dementia the proportion of these periods of improvement resembling recovery only amounted to about 2’6 per cent., or in a somewhat wider acceptation to 4”1 per cent. If we take all those cases together who were able to live in freedom without difficulty, and to earn their living, the proportion would rise to 13’3 per cent., and it would mount to about 17 per cent., if those patients were also counted, who, it is true, have experienced a distinct change of their personality, but still are to a certain extent able to live in freedom. The remainder, without regard to the cases which were not sufficiently elucidated, consists of those patients who indeed did not require further institutional care, but still on account of remaining disorders were not able to manage without special care.

When the patients again fall ill, it is frequently in the same form as the first time, but sometimes it takes one of the other forms described above. Indeed this alternation of clinical forms, which is occasionally noticed,— depression, excitement, stupor, paranoid states, is, as in manic-depressive insanity, an important proof of their inner connection. The disorders may, according to the kind of relapse, appear again slowly, acutely or subacutely. Not at all infrequently there is seen, as in the first attack, after the initial improvement a gradual deterioration of the psychic state developing very slowly, till years afterwards more severe morbid phenomena appear.

CHAPTER VII. ISSUE—TERMINAL STATES

The consideration of states of improvement is of the greatest importance for the question of general prognosis in dementia praecox. According to my former grouping into hebephrenic, catatonic and paranoid forms I had come to the conclusion that in about 8 per cent. of the first and in about 13 per cent. of the second group, recovery appeared to take place, while paranoid forms probably never issue in complete recovery. These statements have been much disputed. The differences of opinion have certainly more to do with the limitation of what is to be regarded as recovery. Meyer found, when he followed their fate, 20 to 25 per cent. of his patients “with catatonic phenomena” so far restored after a few years that they could follow their calling and appear healthy to their neighbours. Racke, who after three to seven years made enquiries about his cases, found that of 171 catatonics 15’8 per cent. might be regarded as “practically well,” a number which does not materially diverge from my statement. Kahlbaum found recovery in one-third of the cases of catatonia. On the other hand Albrecht reports that among his cases of hebephrenia no real cure was observed; in catatonia and in paranoid dementia on the contrary a few cases of recovery occurred. Stern saw recovery in dementia praecox in 3’3 per cent. of his cases; Mattauschek observed recovery in hebephrenia in 2’3 per cent., in his depressive paranoid form in 11 per cent., in the catatonic form in 55 per cent., in real catatonia in 4 per cent., and in dementia paranoides no recoveries at all. Zendig in his investigations arrived at the view that not a single genuine case of dementia praecox could be regarded as really completely recovered; Zablocka also has taken up this view in his report on 515 cases. Schmidt who had over 455 histories at his disposal, states that in 57’9 per cent. dementia had supervened, in 15’5 per cent. recovery with defect, and in 16’2 per cent. a cure; the remainder had died.

There are various grounds for the contradictory nature of these statements. In the first rank of course the delimitation of dementia praecox comes into consideration. We shall see later that on this point, in spite of the ease with which the great majority of the cases can be recognized, there is still great uncertainty. This is true in regard chiefly to the placing of the paranoid forms which are reckoned with dementia praecox sometimes to a greater, sometimes to a smaller, extent, as also in regard to cases in advanced age in which likewise the arrangement in proper order in our morbid history may be variously handled. As in general the widening of the limits in both directions increases the number of cases which are prognostically unfavourable, there are here some causes for the variation of the figures got for recovery.

Further difficulties arise from the varied delimitation towards the domain of amentia, and of manic-depressive insanity. The cause of that lies in the importance, sometimes greater, sometimes less, which is attributed to the appearance of the so-called “catatonic” morbid symptoms about the extent of which, moreover, opinions are likewise varied. In any case there still exists to-day to a not inconsiderable extent the possibility of cases of amentia and of manic-depressive insanity being wrongly attributed to dementia praecox and vice versa; the prognosis of the disease will accordingly be more favourable or more unfavourable.

In this uncertainty about the delimitation the statements of different observers can in the first place not be compared at all, not even the diagnoses of the same investigator at different periods of time separated by a number of years. But, even if this difficulty did not exist, we should further have first to agree about the idea of cure. To begin with, the degree of recovery must be taken into account. Meyer evidently does not make the very strictest claims, and Racke speaks frankly of “practical” cures. But in dementia praecox in a considerable number of cases all the more striking morbid phenomena may disappear, while less important changes of the psychic personality remain, which for the discharging of the duties of life have no importance, but are perceptible to the careful observer, who need not always be a relative. As the most manifold transitions exist between complete disappearance of all the disorders and these cases of “recovery with defect,” the delimitation of recovery in the strictest sense is to a certain extent arbitrary, but just as much so also the determination, where “practical” cure passes into distinct psychic decline. On this account also the figures of different investigators will of necessity diverge from one another. Further also there is the possibility that in certain circumstances slight peculiarities which were already present before the patient fell ill, but which had remained unnoticed, or which are dependent on other conditions, may be wrongly regarded as consequences of dementia praecox.

But lastly, attention must be directed to improvement with later relapse, which has already been treated in detail. As improvement, which resembles recovery, may certainly persist far longer than a decade, we shall be able to pronounce a final judgment about the issue of an apparently cured case only after a very long time, and must even after ten or twenty years make up our minds to having few cases verified. In the majority of the researches, hitherto communicated, the time which has passed since the commencement of the improvement is much too short for the figures to give now a final decision on the prognosis of dementia praecox. Meyer, indeed, has taken up the standpoint that in relapses after a considerable time we have to do with fresh attacks of the disease and thus are quite justified in speaking of recoveries. It might, however, considering the many gradations in the length of the intervals, and in the severity of the slighter morbid symptoms which continue during their course, be quite impossible to determine the point when we no longer have to do with a flaring up of the morbid process which has been so long at a standstill, but with a really fresh attack of the disease. Later we shall, moreover, learn still other grounds which give evidence of an inner connection between attacks which are similar to each other though separated by considerable intervals of time.

It is the difficulties here explained in detail which cause me for the moment to refrain from laying down new values for the prospects of cure in dementia praecox. In any case for a very considerable number of apparently cured cases it will not be possible to bring forward now with any certainty the objection that it was a case of mistaken diagnosis or of temporary improvement which later was followed by relapse. On the other hand it will not be possible at the outset to deny the possibility of complete and lasting cure in dementia praecox. If a morbid process can remain quiescent for twenty-nine years, as in one of the cases observed by myself, it will probably be able also to attain to a complete cure. Still, the severe relapses after comparatively long and perfectly free intervals must suggest the thought that, as in paralysis, we have often to do only with a standstill or with extremely slow progress, but not with a real termination of the morbid process. The experience is, however, worthy of notice, that even among the cases which terminate unfavourably, which form the foundation of my clinical statements, many forms in a third of the cases, indeed in more than half, exhibit marked improvement, but which gives way sooner or later to a relapse. As the frequency of essential improvement in any other disease could scarcely be much greater, it may reasonably be thought that the cases terminating unfavourably, which I selected, on the whole represent the general behaviour of dementia praecox. Further researches into extensive series of cases observed carefully throughout decades must show how far the view, which is gaining in probability for myself, is right, that lasting and really complete cures of dementia praecox, though they may perhaps occur, still in any case are rarities.

An almost immeasurable series of intermediate steps leads from cure in the strictest sense to the most profound dementia. According to my former statements 17 per cent. of the hebephrenic and 27 per cent. of the catatonic form seemed to me to issue in a moderate degree of weak-mindedness, while profound dementia occurred in the former in 75 per cent. of the cases, in the latter in 59 per cent. Among other observers Zablocka found for hebephrenia in 58 per cent. of the cases slight, in 21 per cent. medium, in 21 per cent. high grade dementia; the corresponding values for catatonia were 58 per cent., 15 per cent., and 27 per cent. Mattauschek reports for hebephrenia over 9’3 per cent. recoveries with defect, 20’9 per cent.