Studies in Forensic Psychiatry - Bernard Glueck (grave mercy .TXT) 📗

Maudsley[1] has long ago said: “It would certainly be vastly convenient and would save a world of trouble if it were possible to draw a hard and fast line and to declare that all persons who were on one side of it must be sane and all persons who were on the other side of it must be insane. But a very little consideration will show how vain it is to attempt to make such a division. That nature makes no leaps, but passes from one complexion to its opposite by a gradation so gentle that one shades imperceptibly into another and no one can fix positively the point of transition, is a sufficiently trite observation. Nowhere is this more true than in respect of sanity and insanity; it is unavoidable, therefore, that doubts, disputes and perplexities should arise in dealing with particular cases.”

No small amount of the disrepute into which expert medical testimony has fallen is due precisely to a failure on the part of the legal profession to appreciate these truisms. To the legal mind the transition from mental well-being to mental disease is exemplified by that wholly artificial, and to the psychiatrist’s mind, subsidiary question of legal certification. The law takes no cognizance of the conditions necessitating this change; it only concerns itself with the delimiting frontier, viz.:—certification. Legally, the insane has become such through the filling out and signing of certain papers and through having submitted himself to a certain prescribed legal procedure. The physician, on the other hand, because of his peculiar relationship to the patient, and as a result of his particular training, looks upon this legal procedure as a necessary evil and merely as typifying the conventional mode by which society settles its accounts with its diseased members. Our legal brethren fail to appreciate, furthermore, the fact that an individual may be very seriously ill mentally and urgently require hospital treatment, without, however, showing those gross disorders of conduct which go to make up the legal evidence and diagnosis of insanity. Neither do they seem to recognize the possibility of a seriously unbalanced individual making quite a normal impression, at any rate before a jury of laymen at the time of his appearance in Court. Nowhere in psychiatry is this so apt to be the case as in that form of mental disease known as paranoia, where we are dealing with a diseased personality which in many respects still approaches and resembles normal man.

The paranoiac, while he may harbor the most intricate and well-organized system of delusions, still remains approachable to us, and intellectually may be not only on a par with the average normal individual, but not infrequently gives the impression of being his superior. Nevertheless, this usually well-endowed human being at a certain point in his career goes off at a tangent and spends the rest of his life in the pursuit of a phantom. The paranoiac, starting out with vague, ill-defined ideas, succeeds in elaborating, step by step, a well-organized system of thought, of ideas which finally assume an all importance in the conduct of his life and remain unshakable.

Kraepelin[2] defines this condition as a mental disorder which is essentially characterized by a gradual and systematic evolution of a well-organized and intricate system of persecutory and grandiose delusions. It is chronic and incurable in its course and does not lead to any appreciable deterioration in the intellectual sphere. The litigious form of this disorder is particularly characterized by a persistent and unyielding tendency toward litigious pursuits. It is for this reason that this form of paranoia is of particular interest forensically. The law is the tool with which these individuals work, and the Courts their battle-grounds. The least provocation suffices to start the stone rolling, launching the unfortunate upon a career of endless litigation. As a rule the disorder originates in connection with some adverse decision or order of the authorities, which the patient considers an unjust one. Whether injustice has actually been suffered by the patient matters not and remains absolutely of no consequence as far as the course of the disease is concerned. The paranoiac litigant is unable to see the law as others see it, and in this respect he does not differ greatly from primitive man, whose conception of legality is that of a collection of concessions for himself and prohibitions for others. To be sure, a tendency to excessive litigation is occasionally met with in what appear to be normal people. Such pursuits, however, become pathological when they are based upon a delusional interpretation of actual occurrences or upon actual delusions, and are not amenable to reason.

According to Tanzi[3] the theme underlying the delusional system of litigious paranoiacs is avarice, and the whole may be looked upon as the slow and permanent triumph of a preconception. “The paranoiacal preconception gradually conquers all evidence to the contrary, and in spite of reality, public opinion and common sense, it becomes organized into a coördinated system of errors which become the tyrants of the intellectual personality and remove it by degrees outside the bounds of normality.” The litigant constantly busies himself with his grievances, loses all interest in everything else, and begins to fight for his rights. He stops at no means and is the bane of judges and court officials. Naturally, he has to be refused all aid, either because he is unjust or because the courts find no remedy for his troubles. He refuses to settle actual grievances, carries the case from one court to another and finally develops an insatiable desire to fight to the bitter end. The statutes appear to him inadequate and even the fundamental principles of law fail him. He cannot abide by the ultimate decision after all the usual means of justice have been exhausted. In his attempts to gain justice he writes to magistrates, legislators and various other people in prominence. It is only after years of persistent misfortune both to himself and the objects of his delusions, which only serve to harden him against his fortunate opponents, his incapable lawyers, the corrupt judges and his ignorant and craven-hearted relatives, that this master of procedure is betrayed into the expression of threats or the commitment of some other offense which conveys him summarily from the civil to the criminal courts, and the unrepentant pursuer becomes the defendant, unless, indeed, the insane asylum has become his refuge. (Tanzi.)

This is precisely what happened with the patients whose histories are here recorded. With all this the paranoiac remains plausible, converses rationally and coherently, shows himself to be exceedingly well-informed on current events, amazes his listeners with his really wonderful memory and his ability to quote ad infinitum from law books and statutes. Absence of hallucinations is the rule. Memory and the capacity to acquire new knowledge remain intact, and reasoning and judgment on matters of everyday life which do not touch his more or less circumscribed delusional field may remain quite normal. In short, he shows none of those tangible signs and symptoms upon which we must so frequently rely in our efforts to convince a jury of laymen of the existence of mental disorder. It is only when we take into consideration the entire life history of a paranoiac, which unfortunately is frequently ruled out as hearsay evidence, that the real state of affairs becomes manifest. We then see that where it concerns his delusional field the paranoiac’s judgment is formed, not as a result of observation, or logic and reasoning, but as a result of an emotion, a mere feeling that this or that proposition is true. In every adverse decision of the court he sees a deep-laid conspiracy to deprive him of his rights. His lawyers are incompetent and in collusion with his persecutors; the judge is corrupt or ignorant of the law, and the legislators negligent in their duties in not writing into the statutes laws which would take care of his grievance. He constantly harps upon what he calls “the principle of the thing”, losing, gradually, all concern in the real issues involved.

Indeed, in watching the amount of attention a paranoiac bestows upon his grievances, the zest with which he takes up every newly discovered flaw in the law, and the dexterity with which he weaves it into the maze of his delusional system, the idea forces itself upon one’s mind that what the paranoiac least desires is a settlement of his grievances. One can readily imagine the void in the unfortunate’s life were he to be deprived of this all-engrossing, and to him really life-giving, casus belli. Thus, not infrequently, when one grievance is actually settled, another soon appears and assumes the center of the stage. The means these individuals use in their efforts to convince the authorities of the righteousness of their cause or of the genuineness of the persecutions to which they are subjected, are really amazing in their ingenuity. They are supported to a considerable extent by retrospective falsifications of memory, and when occasion arises, by a conscious distortion of facts, and prevarication, a point very justly emphasized by Bischoff.[4]

This author relates the case of a paranoiac woman who was in litigation with her father over some trifling inheritance left by her mother, and who accused her father of a murder, and insinuated that she had heard her grandfather call him a fratricide.

The reputation and character of the objects of their delusions are unsparingly attacked by the paranoiac litigant, and this not infrequently results in bringing matters to a head, where as defendant in a criminal suit for libel the paranoiac is recognized in his true light and sent to a hospital for the insane. Before, however, this final scene in the litigious career is enacted, especially where the persecuted has turned persecutor, the objects of his delusions have not infrequently suffered an untold amount of anguish and financial ruin, through having been obliged to play the part of defendants in civil suits based on nothing else but the distorted fancy of a diseased mind.

While one may readily detect the part played by avarice in the pursuits and activities of these individuals, it requires close contact with them, especially in the capacity of one who stands between them and freedom, in order to fully appreciate the degree of malevolence which they frequently exhibit. Indeed, the study of litigious paranoia, more than anything else, illustrates how much method there may really be in madness. Were an alleged lunatic standing as a defendant in a criminal suit to use one-tenth of the amount of ingenuity and conscious direction of his symptoms that the average paranoiac uses, he would furnish the champions of the idea of malingering of mental disease with enough material to convict a dozen lunatics.

The chief aim of this paper is to illustrate by means of two interesting case histories the forensic importance of this form of mental disorder. It is not intended, however, to enter here into an academic discussion of the problem of paranoia. The term “Paranoia” is even pre-Hippocratic, and any attempt to indicate, even in the briefest manner, the changes which this concept has undergone throughout the ages would require considerably more space than we have at our disposal. I shall, therefore, merely mention that in reviewing the history of paranoia one is unmistakably struck by the fact that those view points and ideas concerning this subject which have indelibly impressed themselves upon it occupy themselves with a study of the personality of the paranoiac rather than with the disease picture as such. Some of the investigators have gone so far as to maintain that paranoia is not a disease at all in the