CHAPTER XXXII

THE DIAGNOSIS OF PSYCHOPATHIC STATES 

IN the investigation of psychopathic states the psychopathologist finds a strikingly characteristic pathological condition in each individual case. The symptoms are not isolated, they are not the results merely of nervousness, as is usually and superficially explained both by the laity and the physician. The symptoms of a psychopathic case are intimately related and are in each case due to one underlying pathological state.

    The symptom-complex is grouped round a pathological nucleus of sets of subconscious systems, controlling and guiding the morbid manifestations. Success in the treatment of a psychopathic case depends on the ability to get at that pathological nucleus of the subconscious systems and have it disintegrated. Unless this is done the psychotherapeutic treatment is either ineffective or is but a temporary makeshift; it does not really cure, but only helps to cover temporarily a pathological focus.

    We must always attempt to get at the central, pathological, subconscious system out of which all the morbid manifestations arise. Thus in a well developed psychopathic case the dizziness, the faintness, the nausea, the indigestion, the hemicrania, anaesthesia, and hyperaesthesia, the fatigue, the abulia, insomnia, and general depression bear severally definite relations to some pathological focus, which the psychopathologist must find by a searching examination before an effective psychotherapeutic treatment can be undertaken.

    This pathological focus underlying the total morbid symptom-complex can be proven, by various methods, to be detached, or as it is termed, dissociated, from the patient’s normal mental life. In the course of time, if it persists and keeps on growing and proliferating, it may become organized into a parasitic cancerous growth, capping the vital energies of the normal personality.

    This parasitism is well brought out in the attitude of the patient, especially in psychoneurosis, towards those morbid manifestations. He regards the whole symptom-complex as foreign to his personality. “When the attack is on,” one patient tells me, “I am conscious of everything, and still I have no control.” “Something has happened,” says another patient, “over which I have no control.” “What a fool I am to be troubled by such nonsense; but I cannot help it when it comes.”

    Another important characteristic is the periodicity of remissions in the appearance of the morbid system. The attacks of functioning of the dissociated morbid system run in cycles. During the attack the mind works in a circle. This is an important pathognomonic symptom of psychopathic affected: cyclical and circular mental movements.

    The attack itself is usually sharp and brief in duration and is followed by a long period of depression and worry. It is like a controlling nucleus embedded in a mass of nourishing cytoplasm. Acute sensory attacks with long intervals of brooding are pathognomonic of psychopathic states. This brooding, of course, may be conscious or subconscious, but it is there, and it is of the utmost consequence for the psychopathologist to uncover it, if he wishes to diagnose the case scientifically, and introduce a rational therapeutic treatment.

    In most, if not in all cases of psychopathic states, somopsychosis and neuropsychosis, the origin of the attack or of the obsession is unknown to the patient. The original pathological focus escapes the patient's knowledge just as it is often beyond the grasp of the practising physician. There is a strong, active, pathological mental focus of subconscious systems in the patient’s mind, a focus of which he is not directly conscious.

    In order to come to that pathological focus and clean it out, the patient’s subconsciousness must be skillfully and thoroughly tapped. This subconscious aspect is one of the most important pathognomonic symptoms of psychopathic diseases. It is of great importance in differential diagnosis. If it can be shown that the lost function or affected organ is active subconsciously, then the affection is of a psychopathic character.

    A further diagnostic point is the overactivity of the stimulated subconscious function. Thus psychopathic anaesthesia, amnesia, is also hyperaesthesia and hypermnesia. In functional diseases all losses of functions are also subconscious gains.

    Another symptom well worth knowing in the diagnosis of psychopathic states is the sudden onset of the attack. The morbid mental state flashes on the patient’s mind, keeps him in agony for a brief period, sometimes for but a few moments, like a petit-mal of epilepsy, and then disappears to reappear on some other occasion. These occasions are not accidental; they have a definite causal relation to the attacks.

    Other states persist in consciousness for some time, but even in such cases periodicity of remissions is quite marked. This characteristic of periodicity of fully developed psychopathic states is so pronounced that some writers describe such cases by the term “psycholepsy,” while others classify them under the misused term of “psychic epilepsy.”

    These states do not belong to the patient's normal associative life, but appear to the patient himself as opposed to his usual normal life-activities. They are dissociated from the rest of his interests, from the rest of his associations and psychomotor adjustments. He does not understand these dissociated states for they have no meaning in his present life; they are outlived experiences and reactions, resurrected in the form of hypnoid and hypnoidic-like states. Under certain conditions he is not even aware of them, since they either appear subconsciously, or swamp his personality during the whole period of their activity. The states are essentially subconscious, dissociated states; they come in attacks, in seizures, and manifest themselves, like volcanic upheavals, with extraordinary violence and emotional disturbances.

    As pointed out in a former chapter: “One general characteristic of these morbid psychomotor states is the fact of their recurrence with the same content of consciousness and with the same, almost invariable psychomotor reactions. The patient thinks, feels, wills and acts in the same way. Subconscious dissociated states belong to the type of recurrent moment-consciousness,—a type characteristic of the lower forms of animal life, a type that responds to the external environment with the same adjustments, with the same psychomotor reactions. From this standpoint we may regard the recurrent psychomotor states as a reversion to lower forms of consciousness. The suddenness of the attack, the uniformity of the manifestations of the symptom-complex, the uncontrollable, overpowering effect on the patient’s personal consciousness are all due to the same underlying condition,—the dissociation of the patient’s subconsciousness.”

    During the predominance of the recurrent states, the sense of reality is affected, since the subconscious or dissociated mental states come with an almost uncontrollable insistency and intensity of the sense of their reality. This is especially true of the highly developed and fully systematized complex recurrent mental states. This affection of the sense of reality is still more enhanced by the suddenness and violence of the subconscious eruption.

    The attacks can be traced to mental trauma, emotional shocks, and especially to experiences of early childhood,* to subconscious experiences now purposeless, meaningless, and harmful to the stability of the patient’s personality, noxious to the equilibrium of his psycho-physiological organization, and detrimental to the integrity of his psycho-biological adaptive reactions.

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*This last generalization, advanced in my various writings, will be further developed in a forthcoming work.

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