Studies in Forensic Psychiatry, Bernard Glueck [little bear else holmelund minarik .txt] 📗

between the emotional shock of the crime of murder and the probable punishment for it, and the development of the mental disorder must be taken into consideration. This is not a mere accidental relationship. But even if we grant that this point cannot be definitely decided, the psychogenetic character of this case cannot be doubted when we remember how the entire symptomatology is absolutely dependent upon and influenced by occurrences in the patient’s environment. He refuses to eat, a symptom very common in catatonia, but it is indeed a rare occurrence for a catatonic in the midst of a negativistic stupor and mutism to say, “I’ll drink it,” and actually drink voluntarily the entire contents of the pitcher in order to avoid tube-feeding. He is untidy in his habits, another common catatonic characteristic, but is it to be expected that a catatonic, in the height of his disorder, will abstain from his filthy habits when threatened to be punished for these? Many more instances of similar nature could be cited in this case.

Another feature which removes all doubt of the psychogenetic nature of this disorder is the important part which the mental experience which was active in the production of the disorder played in the fashioning of its symptomatology. I alluded before to the patient’s answer to the question of whether he heard voices.

The disorder itself, as far as the symptomatology is concerned, is not absolutely typical of any one of the acute psychogenetic states. It partakes of Kutner’s “catatonic states in degenerates” as well as Raecke’s confusional hallucinatory disturbances in these individuals. That the patient can be classed as one having a degenerative soil is not at all certain in this case.

I have considered briefly the importance of a proper recognition of these cases from the viewpoint of rendering a proper prognosis. There is another important question which must be discussed in connection with these cases and that is the question of malingering. Picture to yourself an individual, who, to all appearances, has led a normal existence, and never showed anything mentally which might be considered pathologic. He commits a crime, and upon being arrested or upon being placed on trial for his offense, suddenly lapses into a condition of apparently complete dementia. The man, who formerly showed nothing in his conduct and behavior indicative of a mental disorder, suddenly changes into a state where he does not know his name, age, or his whereabout. His answers to questions are irrelevant and of a remarkedly silly coloring. He begins to act in a childish, affected manner, executing many silly, meaningless acts, or he may break out in a wild furious excitement, loudly proclaiming his innocence, and threatening those who arrested him. In addition to this, it is noted that this apparently pathologic condition can be definitely influenced by using strict and positive measures. The untidy habits of the patient may be corrected by urging or threats. The man who has been mute and refuses to eat can be made to talk and eat voluntarily by threatening him with tube-feeding. Furthermore, in the midst of this apparently total dementia, total blocking of all thought processes, the patient frequently surprises those about him by very sensible remarks of a very clever and pertinent nature, indicating that although apparently oblivious of his environment, he knows what is going on about him.

A picture like this may readily arouse the suspicion that we are dealing with a malingerer, and, indeed, some very prominent German psychiatrists have reported as malingerers cases similar to this. The trained psychiatrist, if unfamiliar with this class of cases, will find himself at a loss to know under what known group of mental disorders to place this condition, as it will at once become apparent to him that it does not fit into any of the well-known psychoses.

In defense of the genuineness of the psychotic manifestations of these patients, I would recall again the transitory mental disturbances of students undergoing examinations. The genuine loss of all knowledge of well-known facts which the old-time strict and severe schoolmasters frequently provoked in school children, differs very little from the pseudo-dementia with which we are dealing here. It concerns a similar total blocking and inhibition of all thought processes, and, like all psychogenetic disorders, has a tendency to disappear upon the removal of the causative factor.

Still, nobody would think for one moment that the child malingers when it is unable to answer questions, though these might concern well-known facts. The consequences of failure to recognize this acute prison-psychotic-complex as a genuine mental disorder may prove to be very disastrous when we remember to what extent the symptomatology of these psychoses is dependent upon environmental conditions.

The Degenerative Psychoses

I have considered thus far those psychogenetic mental disorders, the etiologic factor of which consisted of a single, more or less isolated emotional occurrence. We have seen that the majority of these patients showed very little, if anything, in their past life which was in any way incompatible with leading a more or less successful existence in the community in which they lived. These patients, we might say, would never have been brought to the attention of the psychiatrist had it not been for the occurrence in their life of an experience which provoked a mental breakdown.

I will now consider a group of cases, in whom the degenerative soil is so prominent that they have been properly called “Psychoses of Degeneracy.” They should, however, be considered here, because the various psychotic manifestations of these individuals are purely psychogenetic in nature, and evoked by a certain milieu in which the individual was placed. As my material is derived from the criminal department of the Government Hospital for the Insane, the causative factor in these cases will again be found to be imprisonment. These cases differ from the so-called acute prison-psychotic-complex in that the etiologic factor does not consist in a single emotional experience. We are not dealing here with patients in whom the commission of a crime is an accidental occurrence in their life, that is, still uncorrupted individuals upon whom the criminal act in itself might act in a deleterious manner. The patients belonging to this group are, as a rule, old offenders, who have long been hardened to crime, and whose entire life is an uninterrupted chain of conflicts with the law. To this group also belong those high-strung individuals with early antisocial tendencies, who from childhood show a marked degree of egotism and self-love; who are very vindictive and revengeful in their reaction to frictions in social life. Upon falling into the hands of the law, they are incapable of adjustment to the new situation, react in an insane and wild manner to the prison routine, and, in consequence, frequently commit grave offenses during imprisonment.

We owe our present knowledge of the psychopathology of these individuals to the excellent work of the followers of the great Magnan, who contributed so richly to the study of degeneracy.

Siefert[9] was the first to clearly differentiate the purely endogenetic disorders from those dependent upon a degenerative soil, and evoked exclusively by outside influences. He divided the eighty-seven cases of psychoses in criminals studied by him into two distinct groups, namely, the real psychoses and the degenerative psychoses. Under the former thirty-three cases he places the well-known forms of dementia præcox, epilepsy, paresis, etc. These, according to him, are not in the least influenced by the milieu in which they occur (in this instance, prison environment). His fifty-four cases of degenerative psychoses, on the other hand, were characterized above all by the fact that they stood in the most intimate relation with the environment in which they occurred, and were wholly influenced by the same. The pathologic, degenerative soil which permitted of the development of the psychosis in these individuals consisted of irritability, lability, autochthonous fluctuations of mood, fantastic day-dreaming, a heightened subjectivity to the environment, inability to form correct critical judgment concerning unpleasant occurrences about them and a strong tendency to suggestibility. On the physical side these patients were subject to headaches, migraine, restlessness and anxiety, often associated with disturbances of heart-action, hypochondriacal complaints, and a tendency to become easily tired upon physical or psychic exertion. They also showed, as a rule, intolerance for alcohol, and were wont to react to alcoholism in a strongly pathologic manner.

Siefert divides his fifty-four cases of degenerative prison psychoses into the following groups:—

First:—Hysterical degenerative state. These consist of undoubted cases of grave hysteria, with convulsions, physical stigmata, endogenous states of ill-temper, confusional states, Ganser twilight syndromes, etc.

Second:—Simple degenerative states. These differ from the preceding group in that hysterical stigmata are wanting. These patients are subject to severe maniacal outbreaks, motor excitements, mutism, attacks of anxious, delirious states, with confusion, etc.

Third:—Fantastic degenerative forms. This group concerns markedly degenerated individuals with a pathologically exaggerated imaginative faculty, a strong auto-suggestibility, a tendency to deceit and lying, to inherent fluctuations of mood and hysterical stigmata. On this basis there develop conditions of pseudologia-phantastica, systematized delusional formations of all sorts, delirious psychoses, etc.

Fourth:—Paranoid degenerative forms. This group he again subdivides into the querulent and hallucinatory paranoid forms. The former may resemble the typical “Querulantenwahn”, a psychosis artificially built up out of extraneous circumstances, and one which rarely develops in freedom, but is of very frequent occurrence in prison. The hallucinatory paranoid form consists of fallacious sense perceptions and delusions of a persecutory nature, often substantiated by a strongly hypochondriacal element; in short, a picture which simulates very closely the real paranoid state.

Fifth:—Prison psychotic states with simulated symptoms.

Sixth:—Dementia-like processes. The individuals belonging to this group are habitual criminals in whom the criminal tendencies become evident at a very early period in life, and who, without giving distinct evidence in their past history of a mental disturbance, develop after prolonged confinement a progressive change of character which eventually leads to frequent rebellious outbreaks against the prison management. They become absolutely unmanageable, neglect their work and duties, and finally have to be transferred to an insane asylum. Here they show nothing characteristic of the well-known dementing processes, as hebephrenia, for example; but very frequently, although quite young, their entire manner and behavior suggest a certain dilapidation and deterioration.

Siefert considers the above-mentioned disease processes as entirely dependent upon and provoked by prison life, in individuals with a tendency to mental deterioration. He comes to the conclusion that the prison psychoses are reactions of pathologic nervous organizations to definite deleterious conditions of life. They are nothing more than irradiations, distortions, and new creations, on the same degenerative soil which also conditioned the crime.

The importance of Siefert’s momentous work cannot be doubted, but whether he was justified in his many subdivisions of the degenerative states is questionable. His own description of the various forms immediately suggests the difficulty of clearly differentiating one from the other.

Bonhoeffer,[10] in a monograph devoted to the subject, endeavors to establish the existence, on the basis of degeneracy, of acute psychotic processes which do not belong to either the manic-depressive, hysterical, or epileptic temperaments, which cannot be placed under any of the known forms of dementia præcox, and which develop as wholly independent psychotic manifestations in particularly predisposed individuals. The material which served for his thesis was gathered from the Berlin Observation Ward for Criminals, among the inmates of which institution he found a great number of degenerative psychoses. In a recent work on the subject of psychogenesis he upholds his former views, and believes he has been able to separate his cases into three distinct groups. The first group comprises certain unstable individuals who show a tendency to the development of simple