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

inflammable, hair-trigger, emotional type of individual who, when thrown into a stressful situation, is very likely to go to pieces mentally. It is a type which is always very difficult to manage under a prison régime, and which in my estimation requires some intermediary place between a hospital for the insane and a penal institution. It is likewise quite irrational in our judicial disposition of these cases to impose a definite sentence. If our prisons are to function as reformatory institutions, it is quite clear that in this particular case no one can possibly foretell how long a period it would take to bring about a reformation. It is as if a man suffering from pulmonary tuberculosis were told that he must go to a place set aside for such as he and stay there, say, five years, irrespective of whether he is well at the end of that time, or whether he might have recovered long before the expiration of that period.

In this particular instance we were led to recommend a commutation of the unexpired term of the sentence by the following considerations: First of all, I cannot consider sodomy a crime punishable by imprisonment, unless the act was performed on a subject who either is incapable of giving his consent or becomes a party to the act against his will, by force. Anomalies of the sexual function are not crimes, but diseases, and as such should come under the purview of the physician, and not the agents of the law. In the second place, this man served in the navy with an excellent record for about two years, and, so far as we know, is not inclined to habitual criminality, and therefore deserved at least another chance. But these considerations are somewhat beside the issue under discussion. The case, to my mind, illustrates very well how closely malingering of mental symptoms is related to actual mental disease, how both manifestations are expressions of the same underlying diseased soil, and how difficult, nay even impossible, it is to tell in a given case which of the symptoms are real and which shammed. On his first admission this man suffered from a grave mental disorder, from which, so far as anybody could determine, he made a complete recovery. Thrown back into the same stressful situation, he again finds himself unable to cope with it, becomes melancholy, suspicious, and mildly delusional. There is, however, considerable doubt in my mind as to the genuineness of these symptoms; unquestionably genuine is only the psychopathic make-up of this individual, which under stress permitted the development in one instance of a grave psychosis, in another of malingering.

Cases like the foregoing are by no means exceptions in criminal departments of hospitals for the insane. It is on account of this type of prison population that penal institutions furnish us with ten times as many insane as free communities.

Whatever convictions I possess concerning the subject of malingering were gained from a fairly extensive experience with insane delinquents at the Government Hospital for the Insane, and when I assert that I have yet to see a malingerer who, aside from being a malingerer, was likewise normal mentally, I do so with the full consciousness that my experience has been a more or less one-sided one. I mean to say that the material observed by me came to my notice within the confines of a hospital for the insane, and that my failure, therefore, to see the so-called pure malingerer is probably due to this circumstance. I shall not argue this point further, but merely state that it is true I have not had experience with the detected and convicted malingerer in the jail and court-room. I have had ample opportunity to study this same genus later as a patient in the hospital.

It would be an extremely interesting study to follow up the later careers of the so-called detected malingerers who are sent to prison and see how many of them later find their way to hospitals for the insane. A setting forth of these figures—and I doubt not for one second that the number is not at all inconsiderable—would not in the least have to be construed as a criticism of the diagnostic acumen of the original investigator. It would simply substantiate the truth of our contention that in the malingerer we see a type of individual who is far from normal, and in whom malingering as well as frank mental disease is not at all a rare phenomenon.

I have no doubt whatever that a considerable number of suspected malingerers are annually sent to penal institutions, there to be later recognized in their true light and transferred to hospitals for the insane; else it would be difficult to account for the fact that mental disease, according to many authors, is at least ten times as frequent among prisoners as it is among a free population. Certainly this cannot be attributed to environment alone, especially not to that of our modern, well-conducted prisons. The reason lies chiefly in the type of individual who populates our prisons. A number of them are either insane when sent to prison or potentially so, and when thrown into a more or less difficult situation, such as imprisonment, readily develop a mental disorder. We see this illustrated very well in the highly beneficial effect which transfer to a hospital for the insane has upon these individuals. I am convinced that one would not be wrong in agreeing with the opinions quoted below, that malingering, as such, is a morbid phenomenon and always the expression of an individual inferior mentally. It may be looked upon as a psychogenetic disorder, the mere possibility of the development of which is, according to Birnbaum[11] and others, an indication of a degenerative make-up, a defective mental organization. Siemens[12] says: “The demonstration of the existence of simulation is not at all proof that disease is simulated; it does not exclude the existence of mental disease.” Pelman holds simulation in the mentally normal to be extremely rare, and he always finds himself at a loss to differentiate between that which is simulated and that which represents the actual traits of the individual. Melbruch[13] holds that simulation is observed solely in individuals more or less decidedly abnormal mentally, because in the great majority of cases, if there does not actually exist a frank mental disorder, these individuals lack in a marked degree psychic balance and are constantly on the verge of a psychosis. Penta, in a most thorough study of the subject of malingering, likewise comes to the conclusion that it is always a morbid phenomenon. It is a tool almost always resorted to by the weak and incompetent whenever confronted with an especially difficult or stressful situation. It is, therefore, almost exclusively seen in hysterics, neurotics and other types of psychopaths, in the frankly insane, and in grave delinquents.

With these remarks concerning malingering in the supposedly mentally normal, we may turn to a discussion of that large group of borderland cases which furnishes, outside of the frankly insane, the great majority of malingerers. I am tempted here to borrow Bornstein’s classic description of the type of personality to which I am referring. According to him, these individuals come into the world with the stamp of a hereditary taint, with certain somatic anomalies (ears, palate, formation of skull, growth of hair, etc.), and already as children show those psychic characteristics which are decisive for their individuality. They are, above all, characterized by a marked hypersensitiveness and by a lack of harmonious relationship between the various psychic functions. This disharmony finds its expression chiefly in the predominance of the emotional element over the intellectual and in the entire subordination of the latter to the former. Their feelings, furthermore, express themselves in an abnormal manner, both as regards their intensity and duration. The emotional reaction is either excessively strong or, on the other hand, disproportionately weak compared with the stimulus, and in spite of the extravagance of the expression it quickly passes over or remains with an excessive obduracy for a disproportionately long time. Notwithstanding the apparent intensity of the outbreak in the former and its tediousness in the latter case, these emotional upsets almost always lack real depth. They are usually very superficial, insufficiently grounded, rather dependent upon accident; transitions from one extreme to the other make up the daily experiences of these individuals—from intense love to burning hatred, from deepest reverence to an irreconcilable disgust, from unshakable loyalty to brutal treachery. They lack energy and initiative, are undecided, vacillating, and inclined to self-reproach. The domination of the emotional sphere and the frequent incongruity and discord between the various forms of emotional expression frequently lead to the development of morbid doubts, morbid fears, a morbidly exaggerated egotism, and sensitiveness which leads them to scent everywhere personal injury and insult. Finally, they frequently show an overdevelopment of the sexual instincts and various deviations from normal sexual development. Many of them seem to lack totally in the power of reason, but act entirely upon impulse, upon the mere feeling that this or that proposition is true. Many others show a pronounced tendency to a metaphysic brooding and day-dreaming and to the transformation into fact of the dreamed air castles, without any regard to the iron logic of life which they cannot satisfy, with which they either will not or do not know how to reckon. Turning their backs upon the demands of life, centered in self, given up to the kaleidoscopic play of their emotions, which are of short duration, imperfect as to depth, varying in intensity, and depending upon any and every external influence, these individuals are very uncertain in their opinions, judgments, and motives for action. They go through life without any direction, without any guiding idea, without initiative, and without will, incapable of any kind of systematic labor, yet at times ready, under the influence of a temporary affect, to sacrifice everything in order to carry out what later on proves worthless and vain. Lacking in sure criteria and guides, they are slavishly dependent upon momentary external influences, and under unfavorable conditions of life suffer want and misery and give way to temptation, frequently falling into a life of vagabondage, drunkenness, and crime. In prison they often develop mental disorders, are looked upon as malingerers, and oscillate between prison and the insane asylum, only to begin the old game over again so soon as they again come in contact with life.

It is little wonder, then, that the psychiatrist in dealing with these unfortunates frequently finds himself at a loss to tell where health leaves off and disease begins. The psychoses which these individuals develop are in the great majority of instances purely psychogenetic in character, one of the many distinguishing features of which is a marked susceptibility of the symptoms to be influenced by external occurrences. This tendency of the symptoms to shape themselves in accordance with occurrences in the immediate environment frequently leads to the suspicion of malingering, because there seems to be altogether too much discretion displayed by these alleged insane.

I have elsewhere[14] reported a series of these cases and entered into a detailed discussion both of the personality and the nature of the psychoses from which these individuals suffered. Most of my cases had been both in prison and in hospitals for the insane on more than one occasion, every arrest and imprisonment having been apparently sufficient to bring out a fresh attack of mental disease.

The following case is fairly illustrative of this type:—

J. H., white male, age twenty-seven on admission, November 13, 1913. While serving a year’s sentence at the Portsmouth Naval Prison for fraudulent enlistment the patient told the authorities there