Epidemiology and Demographics

Chapter X. Delimitation

Whether dementia praecox in the extent here delimited represents one uniform disease, cannot be decided at present with certainty. In any case we shall no longer need to refute in detail the objection formerly brought from different sides against the establishment of the morbid form, that it was a case of unjustified grouping of uncured psychoses of very different kinds, of melancholia, mania, acute and chronic confusion, derangement. Clinical experience has demonstrated innumerable times that it is possible from the conception of the pathology of dementia praecox to foretell with great probability the further course and the issue of a case belonging to the group; but in saying that, the proof is furnished that our picture of dementia praecox is in the main agreeable to natural laws. Nevertheless, it is certainly possible that its borders are drawn at present in many directions too narrow, in others perhaps too wide.

Paranoid Forms

The most criticism has always been directed against the inclusion of the paranoid forms in dementia praecox. It cannot be denied that the pictures of paranoid states at first sight do not have the slightest resemblance to those of catatonic stupor, of excitement or of dementia simplex. Meantime the diversity among one another of the pictures described, as also all similar experiences in other diseases, such as in paralysis, in cerebral syphilis, in manic-depressive insanity, point to the fact that it is very hazardous to draw conclusions from the clinical states alone as to whether they belong to the same or to different forms of disease. This question can only be decided by the whole course of the malady, and the appearance, gradually becoming always more distinct, of those morbid symptoms which are essential to the disease as opposed to the more secondary, though often much more striking, accompanying phenomena.

If we apply these principles to the case before us, the result is that at least some of the attacks beginning in paranoid form, as before described, issue in quite the same terminal states as the remaining forms of dementia praecox. The delusions, which originally completely dominated the morbid picture for years, may vanish leaving scarcely a trace, may be corrected by the patient, denied or forgotten, while a simple hebephrenic weak-mindedness remains. In other cases again there are, interpolated in a paranoid morbid course, states which bear unmistakably the stamp of dementia praecox, silly excitement with mannerisms and stereotypies or negativistic stupor. Fuchs has described a case in which between two such acute attacks for more than ten years a purely paranoid state was present. Lastly, it must be pointed out that delusions and hallucinations of quite the same kind, as we see them in paranoid cases, occur also in most of the remaining forms of dementia praecox, certainly here in connection with a series of other morbid symptoms. The changing composition of the morbid pictures in a given group of phenomena with sometimes weaker, sometimes stronger characterization of single features is, however, quite familiar to us from the most different clinical groups of forms; we shall therefore not lay too much stress on the occasional absence or more striking appearance of single characteristics for the clinical judgment of the states, and all the less if we see their composition repeatedly change in one and the same case of disease.

In any case we may, as I think, regard it as certain that paranoid states may appear in the course of dementia praecox. The question is much more difficult to answer, how wide the circle of paranoid cases must be drawn, which we are justified in regarding as expressions of that disease. Although it appears to me to be impossible at present to arrive at a definite conclusion on this point, nevertheless I have thought, with reference to the doubt which I expressed before, that I should attempt to make a narrower delimitation. Accordingly I have for the present separated from dementia praecox a part of Magnan’s “delire chronique” and what was formerly called dementia paranoides, now named “dementia phantastica.” On the other hand I have still included in dementia praecox those paranoid forms which pass with comparative rapidity into marked psychic decline and in which, besides delusions and hallucinations, those disorders of emotional life and volitional activity can be demonstrated in more or less distinct form, which meet us so invariably in the disease named. It is proved, as far as I can see, to be wholly impossible to delimit them sharply in any way from the first-mentioned paranoid form. Certainly the grouping which is now attempted is not final; but at present we still wholly lack the hypotheses for a satisfactory solution of the task here before us.

Catatonia

For several other groups of cases also the separation from dementia praecox has been recommended. Tschisch has emphasized that catatonia and dementia praecox are fundamentally different from each other, and Morselli also has come to the conclusion, that catatonia deserves a place to itself; it is curable, and is caused by infections. According to my observations I must consider these views erroneous or at least wholly unproven. Even though after infectious diseases morbid pictures similar to catatonia come under observation, they can still not be grouped together with the very great majority of cases in which such causation can be easily established. Whether catatonic cases may be cured under certain circumstances, was formerly investigated in detail; as a rule, however, they are not cured. Catatonic states may further appear suddenly in each period of dementia praecox, sometimes only after a decade. Then we observe after catatonias exactly the same terminal states as in the remaining forms of dementia praecox; but lastly, the “catatonic” symptoms may be present in the morbid picture in all possible grades and groupings. I see, therefore, no possibility of attaining with their help to a delimitation of an independent clinical form.

Meeus has proposed to delimit a hebephrenic-catatonic group from the paranoid forms and from dementia simplex. I think, however, that we need not recognize this as a separate disease. It represents, strictly speaking, the previous history of numerous cases of dementia praecox, in which a fuller development of the clinical picture takes place later. If one will, one may place the slighter cases alongside the “formes frustes,” as they are described by the French in morbid pictures of another kind, the forms with poorly developed disorders, while the more severe would be compared with perhaps the simply demented paralysis. As numerous cases, beginning first as dementia simplex, later follow the ordinary course of dementia praecox, we have to do, as Diem also has already emphasized, with indefinite boundaries. Nor can I make up my mind to make a special place, as Vogt proposes, for dementia infantilis. It will have to be admitted that the conception of the disease has hitherto been insufficiently elucidated, and that therefore among the so-called cases all sorts of component parts of various kinds may be found. Nevertheless the picture described appears to me to correspond so completely with the dementia praecox of adults, that we may without hesitation ascribe to it the majority of the cases with the proviso of the rejection of extraneous admixtures, as the assumption of a dementia praecox in childhood can present no difficulty to us now.

Psycho-reaction

An extremely convenient solution of all these questions of delimitation seemed to be offered by the “psycho-reaction” brought forward by Much and Holzmann. It was a question of the inhibition in the presence of the serum of certain mental patients of the lysis of human red blood corpuscles effected by cobra poison. As this inhibiting effect was said only to belong to the serum of patients with dementia praecox or manic-depressive insanity, it would have furnished us with a valuable aid for establishing whether definite morbid pictures belong to one of those two great forms, and therewith also to the distinguishing of independent groups. If meantime the fact that the psycho-reaction is common to two groups of forms, which certainly are not nearly related clinically, had not aroused very grave doubts as to its reliability, further investigation has given the result, that there can at present be no talk of a diagnostic peculiarity in that kind of reaction, but that it much rather sometimes appears, sometimes fails, in morbid states of the most various kinds, and also in healthy individuals, just as in the forms named.

Clinical Experience

We have therefore even yet to rely purely on the valuation of clinical experience. The result is, as it appears to me, that we are with great probability justified in connecting the great majority of the cases up to the present brought together under the name of dementia praecox with the same morbid process, and therefore in regarding it as a single form of disease. Everywhere the same fundamental disorders return again, the loss of inner unity in thinking, feeling, and acting, the dulling of higher emotions, the manifold and peculiar disorders of volition with the connected delusions of psychic constraint and influence, lastly the decay of the personality with comparatively slight damage to acquired knowledge and subordinate expertness. These features are certainly not all demonstrable with full clearness in each individual case. But still the general view over a great number of complete observations teaches that nowhere can a state be discovered which is not connected by imperceptible transitions with all the others.

In any case the differences in the individual clinical cases, as soon as their whole development is taken into account, seem to me to be not greater than possibly in paralysis. If one will, one may even in the appearance of simple demented, expansive, depressive, stuporous, galloping, and stationary varieties of the course, with or without remissions, as also of juvenile cases of a peculiar form, recognize a certain general agreement in the principal clinical features of the two diseases. As the delimitation of paralysis is now assured, the objections drawn from the difference of the states to the view of dementia praecox as a unity would be thereby weakened. We certainly miss in paralysis the real paranoid forms, but instead we find them again in cerebral syphilis, the clinical forms of which have a still greater multiplicity to show.

If we may, therefore, also regard the essential outlines of dementia praecox as assured, one must reckon with the possibility, indeed the probability, that progressive knowledge will yet bring us all kinds of rectifications of the limits of the disease. The giving a place to the childish forms of the malady, which certainly requires further investigation, signifies material progress also with regard to our etiological views. Perhaps also the very desirable clearing up of the doctrine of the “late catatonias” will bring us a further increase of forms. On the other hand again perhaps some of the smaller groups will in course of time be got rid of; I think first of this possibility namely for the cases with confusion of speech and those with a periodic course.

The hypothesis has also frequently been brought forward that a morbid process other than dementia may be the foundation of the apparently cured cases. I will not dispute this possibility. Partly it will certainly be a simple mistake in diagnosis mostly to the loss of manic-depressive insanity. But there might well be also other curable forms of disease of different kinds with phenomena like catatonia, which we at present are not yet in a position to distinguish from dementia praecox. Those cases with simple persistence of hallucinations without decay of the personality might also come under consideration. It must, however, be recognized that urgent reasons for the separation of the cases, which do not go on to dementia, are as yet absent. The assumption, that the morbid process of dementia praecox, according to its severity and according to its extent, may not only produce phenomena of loss of different kinds, but also sometimes issue in recovery, sometimes lead to more or less profound dementia, is in itself not improbable. Certainly we shall cherish the eager wish to become clear as soon as it is at all possible, as to which way it will take.

Chapter XI. Diagnosis

The diagnosis of individual cases of dementia praecox has to distinguish the manifold states from a whole series of diseases which outwardly are similar but which are totally different in their course and issue. Unfortunately there is in the domain of psychic disorders no single morbid symptom which is thoroughly characteristic of a definite malady. Much rather each single feature of the morbid state may in like, or at least very similar form, also make at a time the impression of an essentially different morbid process in which exactly the same areas are involved. On the other hand we may expect that the composition of the entire picture made up of its various individual features, and especially also the changes which it undergoes in the course of the disease, could scarcely be produced in exactly the same way by diseases of a wholly different kind; at this or at that point, sooner or later, deviations will be certain to appear, consideration of which makes possible for us the distinguishing of the morbid forms. It may in certain circumstances be very difficult, not only to judge correctly of the diagnostic significance of such deviations, but even to recognize their very existence.

Catatonic Symptoms

Special importance in the establishing of dementia praecox has, not without justification, been attributed to the demonstration of the so-called “catatonic” morbid symptoms. Under this term must principally be understood the volitional disorders first described by Kahlbaum as accompanying phenomena of catatonia, automatic obedience, negativism, mannerisms, stereotypies, impulsive actions. As undeniable as it is, that all these disorders in no other disease come under observation in such extent and multiplicity as in dementia praecox, just as little, however, may the appearance of one, or even of several, of these disorders be regarded as infallible proof of the presence of that malady. Certainly this restriction holds good in very different degree for the individual disorders. Automatic obedience, which represents only a sign of the surrender of the patient’s own volition, is found in a large series of morbid states of the most different kinds, and possesses therefore only very slight diagnostic significance. Impulsive actions and stereotypies come under observation in severe brain diseases, specially in paralysis, in infectious psychoses, in senile dementia, in idiots, and can therefore likewise only be used with great caution for the establishing of dementia praecox. Much more characteristic are negativism and mannerisms, which scarcely accompany any other morbid process uniformly in a pronounced form throughout a long period.

At this point meantime the consideration arises, that it is often uncommonly difficult to decide whether we really have to do with genuine catatonic morbid symptoms or not. Automatic obedience may be simulated by shyness; impulsiveness of action by obscurity of motives in clouding of consciousness with inhibition of the movements of emotional expression; stereotypy by uniformity of volitional actions, as that may be caused by the domination of definite, overpowering ideas or emotions. From genuine impulsive negativism there must be distinguished the surly, stubborn self-will of the paralytic and of the senile dement, the playful reserve of the hysteric, the pertly repellent conduct of the manic, and from the senseless perversities in action and behaviour, as they occur in dementia praecox, the conceited affectation of the hysteric, as also the wantonly funny solemnity of the manic patient. Often it will only be possible to find out these and other similar differences after considerable observation among changing conditions, after having made all sorts of experiments on the conduct of the patients under influences of various kinds; sometimes information is first got from observations in quite other domains about the correct interpretation of the phenomena.

Psychopathic States

If we now consider in order the diagnosis of dementia praecox from individual diseases of another kind, the question first comes before us, how far it may be confused with states produced by morbid predisposition. That among psychopathic inferior personalities a group is possibly found which we may regard as undeveloped cases of dementia praecox, as “latent schizophrenia” according to Bleuler’s terminology, was formerly mentioned. Occasionally there come into notice certain shy, whimsical, queer people, and then perhaps many irritable, unaccountable psychopathies with a tendency to distrust and overweening self-conceit, who may at least with a certain probability be supposed to be suffering from dementia praecox. On the other hand we cannot well accept such an interpretation for the great mass of those morbid states the foundation of which is anxiety and want of self-confidence. If the conduct of life exhibits here ever so many peculiarities and apparent incomprehensibilities, their origin can yet invariably be traced back in one or another way to intelligible motives. Only a small group of childishly weak-minded, weak-willed personalities without initiative, with hypochondriacal failure of volition, seems to belong to the frontier territory of dementia simplex.

Not at all infrequently a commencing dementia praecox is looked on as simple nervousness, hypochondria or neurasthenia and treated accordingly, and still more frequently regarded as moral depravity. The increasing failure in work is connected with exhaustion and over-exertion, perhaps also with the influence of some or other occurrence. Here above everything the decisive points for the diagnosis are the signs of psychic weakness, the want of judgment, the senselessness of the hypochondriacal complaints, the inaccessibility towards the reassuring statements of the physician, the emotional dulness and want of interest, the lack of improvement on relaxation from work, further, the more or less distinct manifestations of automatic obedience or of negativism