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

paranoid psychoses. It concerns patients of a very labile make-up with increased affective reactions, with marked tendencies to impulsions and antisocial acts. These cases are characterized by the fact that they do not concern psychogenetic psychotic exaggerations of a certain temperamental predisposition, but psychically evoked disease states which appear to be irreconcilably opposed to the original personality.

He calls attention to the epileptic seizures of these individuals, which have been so ably described by Bratz.[11] In contradistinction to the genuine endogenetic epilepsy, these patients manifest epileptic seizures as reactions to situations purely psychic in nature. In them, without ever resulting in epileptic dementia, there occur along with the epileptic seizures attacks of unconsciousness, of excitement, dream states, and porio-maniacal outbreaks. They differ from the genuine epilepsy by the absence of the characteristic dementia, of attacks of petit mal, and by the fact that the seizures are never purely endogenous in origin. They are always due to extraneous causes, eminently such of a psychic nature. He believes that more frequently even than actual epileptic seizures are the dream states, excitements, and maniacal outbreaks brought about in these individuals by emotional experiences, and as a result of certain ideas and concepts. He places in this group the proverbial “wild man”, the man who goes into a frenzy upon seeing a policeman, etc. Although alcohol may in these individuals prepare the way, the immediate causative factor, however, is the emotional experience, or the recollection of such an experience.

These psychogenetic excitements of degenerates often simulate symptomatologically genuine epilepsy so far as the ferocity of the excitement and the state of consciousness are concerned. In some cases the retention of suggestibility during the attacks shows clearly the psychogenetic character of the disorder, while in others the tendency toward the theatrical and exaggeration is so marked that we are forced to think of an hysterical component. Certain slight symptomatologic features of these psychogenetic states of excitement in degenerates appear to furnish a differentiating point between them and the true epileptic condition. Bonhoeffer refers to the strong tendency to disgust-evoking manifestations, to copro-practice which manifest themselves in the soiling of the walls and face with excrements, the drinking of urine, etc. Another characteristic is the frequent total misunderstanding of the situation by these individuals in that they consider themselves to be threatened with impending grave physical danger. In consequence of this they manifest a certain over-aggressiveness, which goes far beyond mere protective reactions, and manifests itself in a senseless breaking and demolishing of furniture. These individuals can be easily distinguished by their superficial intellectual endowment, by a tendency to change of occupation, and early criminality. During imprisonment and under the influence of the stress incident thereto, they develop an acute paranoid symptom-complex, a delirium of reference, accompanied by ideas of prejudice, isolated elementary hallucinations, and irresistible desire to a depressive recapitulation of their past, and a nervous, irritable temper. Consciousness is not clouded, and they remain perfectly oriented in all spheres. The duration of the disorder may vary from a few months to two years, with occasional intermissions. The delusional formation continues only for a short period, and in no instance leads to a retrospective change of the content of consciousness. Very frequently the process subsides upon the removal of the patient into a new environment without leaving any change in the personality of the individual. Insight is not always perfect. The delirium of reference and prejudicial ideas concerning the prison personnel may remain unconnected.

The cases belonging to his second group are those well-known pestilent individuals who from childhood show an abnormally affective reaction to frictions in social life, in so far as their highly exaggerated, egocentric self-consciousness permits them to endow every unpleasant experience with a personal note of prejudice. They are the poor martyrs, who somehow never seem to get what is coming to them in this world, who are ever ready to assert their rights and leave no stone unturned until they receive what they consider full justice. Such individuals may pass through life, if fortunate enough, without developing a real psychosis. They are then merely burdensome and uncheering elements within their narrow social sphere. Should they, however, meet with an experience, which to them appears as an injustice, they may at once develop typical paranoid pictures, the characteristic feature of which is that the psychic experience which forms the origin of the trouble remains always in the foreground. Bonhoeffer identifies these conditions with Wernicke’s psychoses of hyperquantivalent ideas. He very justly says: “The narrower the sphere of activity in which these individuals live, the more frequent the opportunities for conflict are offered by law, discipline, and subordination, the easier it is to develop a psychotic exacerbation of the abnormal temperament even on a lesser pathological basis. This is the reason why officialdom and especially the narrow limits of prison life bring out so forcibly these psychogenetic disorders. In prisoners the psychogenetic character of the disorder becomes especially apparent. One sees how in many cases the transfer from one prison to another, to an observation station, to an insane asylum, puts an end to the process. In certain instances the process seems to revive itself again when the individual is placed in a similar environment.”

Of Bonhoeffer’s three subdivisions of degenerative states the preceding one would as a whole appear to me to be especially deserving of a separate classification. Anyone who has had any experience with insane criminals will recall that group of cases in whom the entire psychosis seems to be more or less centered about a certain idea; in most instances, about the idea of not having received a just trial. These individuals, without showing any intellectual impairment, in fact without showing any characteristic which would fit their mental disturbance into any of the known psychoses, constantly evidence a sort of paranoid habitus, a paranoid trend which is exclusively directed against those who had anything to do with their conviction and safe-keeping. The most trivial occurrences in their environment are endowed by them with a personal note of prejudice. The delay of a letter, the refusal to grant some of their unusual requests, an attendant’s accidental failure to sweeten their coffee sufficiently, the slightest deviation from the routine greeting of the visiting physician; in short, any such trivial, insignificant occurrence is at once endowed with a special meaning, and explained in a more or less delusional manner. Yet these individuals can reason in a perfectly rational manner on any subject which is not concerned with their conviction or confinement. They are as a rule intellectually bright and keen, and fail to show any evidence of emotional deterioration. On the contrary, their emotions are of such fine and sensitive nature that incidents which an ordinary individual would overlook entirely, offend them to a marked degree, and are reacted to by them in a very decisive manner. Indeed, one frequently asks himself whether their persecutory ideas deserve to be endowed with the value of actual delusions. I fully agree with Sturrock[12] when he says: “If I refuse to allow a prisoner full scope because he has lifted a knife from the table with which to attack the charge warder, I do not call it a delusion of persecution if he spends the night threatening to murder me because I do not give him justice.” One must remember that this is in a measure the normal attitude of the captive towards the captor, and can be seen in a more or less pronounced degree among criminals enjoying a short respite from the law. The essential point here is not the so-called psychosis, but the soil which made the development possible. Not all prisoners, by far, react in this manner to the prison environment. It is only those degenerative individuals who have shown this well-marked paranoic trend all their lifetime, who furnish these cases. As a general rule these conditions are seen in habitual offenders whose entire life has been a round of conflicts with everything they come in contact, and who, outside of prison, figure chiefly in the saloon and gambling house brawls.

That these conditions deserve a more definite classification than the nondescript paranoid state cannot be doubted. These paranoid manifestations are distinct reactions to a definite situation, in this instance, conviction and imprisonment, of individuals whose peculiarly degenerative make-up makes such reactions possible. The question of the particular coloring which these disorders may assume can only take a secondary position to that of the character or make-up with which we are dealing.

Bonhoeffer further speaks of a certain hysterical element in these cases, but does not believe that on this account these paranoid manifestations should be considered as hysterical. He rather believes that they are more closely allied to the epileptoid temperament. The hysterical component manifests itself in either hysterical stigmata, or, as has often appeared to him, in the fact that the falsifications of memory which these individuals frequently manifest concern themselves solely with the simple overvalued paranoid ideas, and lead to a complete blocking out of unpleasant recollections of the individual’s past career. Thus, previous sentences, imprisonments, etc., are totally forgotten. In this, perhaps, we might see the well-known wish factor of hysteria.

The cases which comprise his third group show such a varying symptomatology that it is difficult to form an exact idea of just what characterizes them.

After perusing the work of Bonhoeffer, one feels that the author’s endeavors to subdivide his material into this or that group are somewhat artificial. Granted that we are dealing with mental disorders, whose existence can be possible only by a certain degenerative predisposition, the question arises, “Of how much practical value is this constant endeavor at classification and subdivision of the psychotic manifestations which these individuals show?” One must acknowledge that the salient feature here is not the particular coloring which these psychoses assume, but, as we have stated before, the soil upon which they develop. At most, we might say that the symptomatology of these psychoses would depend on the question whether it is the ideational sphere which is mostly concerned, or the affective sphere. Turning to Wilmanns’ excellent contribution to this subject one again meets with the same endeavors at subdivision and classification. Lack of space will not permit us to enter into an extensive discussion of this author’s work. We have already indicated here and there in passing, some of the essential points in the views of this author.

One turns with quite a degree of relief to the momentous work of Birnbaum[13] on the Psychoses of Degeneracy. As far as can be ascertained the author does not endeavor to subdivide his degenerative states into so many types and forms. According to him, the essential characteristics of the degenerative psychoses—namely, the extraordinary determinability and influence which outside impressions have upon the disorder, the mode of genesis and the psychological evolution of the delusions, etc.,—may be attributed to the essential ear-marks of the degenerative character; that is, to the exaggerated auto-suggestibility, the great instability of the existing conditions and mental pictures, the disharmony between the perceptive and imaginative capacities and the preponderance of a lively fantastic coloring to the dry thinking of these individuals. They do not form disease processes of a definite characteristic form, but episodic psychotic manifestations on a degenerative soil, and the manifold phases of the collective forms are to be considered as repeated fluctuations about the psychic equilibrium of these individuals. He further noted that the symptomatology of these disorders remained limited to a relatively well systematized delusional fabric, which, however, in contradistinction to paranoia, does not persist for any length