ABSTRACT
With this introduction we can now turn to examine a few case histories in order to see how this theory may explain the reactions observed. A number of excellent cases have been recorded by Hoch and Kirby, and the reader is urged to study these as well if he wishes to get a comprehensive survey of this clinical group.
Catherine M 1 . Age: 24. Admitted to the Psychiatric Institute, November 10th, 1913.
F.H. Information as to the family is confined to the two parents. The mother, who was frequently seen, seemed to be a natural, sensible woman. The father, on the other hand, had been alcoholic all his life, had had two convulsions while drinking, and won little respect from any member of the family, including the patient.
P.H. The patient was said always to have been healthy, from a physical standpoint, although never robust. She got on well at school, and then worked, first as a stock girl, and later as clerk in a department store, where her work was efficient, and she advanced steadily. When a child she played freely with other girls, but little with boys. As she grew older she moved about socially a bit more, made the acquaintance of men as well as of girls, but never cared much for the former, and had no love affairs until she met her husband. She was never demonstrative, but always rather quiet and modest. Occasionally she spoke of thinking that people talked about her, but the informant doubted if she brooded over this, because she was not of a worrying disposition. Considering the ideas which appeared in her psychosis, it is striking that in her normal life she was rather antagonistic toward her father on account of his alcoholism and the cruelty of his speech and manners.
When she met her husband she liked him from the first, although she at no time became really demonstrative. They were engaged for a year, during which time she agreed to a postponement of three months for the marriage, which was suggested by her mother. For some time before this event she was working harder than usual, and seemed a bit worn out. She ceased working a month before marriage and improved physically, although she became rather nervous, that is, she was more easily startled, an accentuation of what had been a characteristic for some years. Her husband stated that at this time she became fearful of the approaching marriage relations, and asked him to be kind to her in this respect. She was married a year before admission. For two and a half months she refused intercourse, and visited her mother’s home a great deal. She finally submitted. She was quite frigid, but became pregnant at once. Her abnormality then became apparent. She kept the fact of her pregnancy to herself for several months, and, when she told her mother, wanted to have an abortion performed. Neurotic symptoms appeared. She became sensitive with her husband, correcting his English, and cried easily. She also began to be anxious about the approaching childbirth, and with this became more religious.
For the first few days after the delivery, she was fussy with the nurse so that two in succession had to be discharged. On the fifth day she woke up, and seeing her nurse lying on the couch beside her bed thought the latter was coloured. On the seventh day she had a dream in which she thought she “nearly died in childbirth”. Then she began to talk of dying for her baby or of having two babies, of dying herself and rising again after Easter Sunday. She became antagonistic to her husband, and, with this, excited and confused, so that she was taken to the Observation Pavilion.
On admission she looked pale and exhausted, had a slight temporary fever and a coated tongue. Her orientation was usually vague, but sometimes she gave fair answers. Her verbal productions were rather fragmentary, and with the exception of some repetitions there did not seem to be any special topics which dominated her train of thought.
For some days the great weakness and the slight fever continued, and then, as it gradually cleared up, there came a change in her mental condition that settled into the state which characterized the rest of her psychosis. She talked less and was often quite inactive, frequently lying with her eyes closed for long periods, or sat or stood about. Such movements as she made were slow and languid. Her expression was either blank, absorbed, or gave the appearance of peculiar perplexity. This last was not infrequently associated with a rather sheepish smile. She was never resistive, and always ate and slept well. With rare exceptions she did not soil herself.
The most interesting feature of her mood reaction was that in a general setting of a slight perplexity there appeared at times, and evidently associated with definite ideas, changes in her emotional state. Sometimes this was a matter of distress or of mild ecstasy, sometimes she became markedly blocked. There was at no time any frank elation, but often an appropriate smile, that is, oppropriate to the situation and to the thought to which she was giving expression at the time. Then, rarely, there were sudden bursts of peculiar conduct, such as throwing herself on the floor or running down the hall. When questioned as to her motive for these acts, she would flush, look perplexed and apparently be unable to explain them.
This perplexity was not merely a deduction from objective observation; she herself frequently complained of it and always in connection with the inconsistency of the ideas which puzzled her. For instance, in speaking to the doctor she said, “I think of you as Bill (her husband’s name) sometimes—I get confused thinking of Bill as God, doctor, lawyer, priest.” Again, referring to her husband, she made these curious statements: “They seemed to speak of him as being in the wrong—the right—it seems that the right devil is the wrong one for me—they say he is not the right one for me; they say he went wrong from the time we were married.” Again, she said that she did not know who her father was, and went on: “It puzzles me, this father business, I knew my father at home and my father in Heaven.” Again, ‘Which God do you mean? Did you say God or father?” A hint as to how this subjective confusion made the environment seem uncertain comes from the statement, “You looked like the devil and yet you were God.” Occasionally she referred directly to the perverted nature of her mental processes, as when she said: “My mind is always wandering back and forth”, or, “If only I could keep at one thing, I wander so!” Such statements are as close as a layman could well come to speaking of free associations. Once she correlated her objective and subjective confusion in the remark, “I thought I was called Mary [eldest sister]; I used to answer to any name; now things are all twisted to me, I can think back too. …”
Her verbal productions dealt with a rather limited range of topics which can be briefly summarized. Many of her thoughts seemed to be centered round her husband. She always knew him when he visited her, but in her thoughts there was a constant change as to his personality. She persistently confused him with the physicians, with her father, and with God, and one remark is typical, “I thought he was God, priest, doctor, lawyer—well, I wanted to go to Heaven; I thought he would still be my husband; I always hoped that I would be home in Heaven.” Not unnaturally with this confusion there were doubts about her marriage. People said her marriage was wrong and her husband bad. Frequently she thought he was dead, or voices informed her that she was not married to him, or that he was the devil in Hell. In this connection she also said that people called her a whore, or it seemed as if she were accused of not being married.
As prominently as appeared the ideas of the invalidity or impossibility of her marriage, to the same extent did her father assume an important rôle for her. As a rule he appeared in religious guise as God—“I knew my father at home and my father in Heaven; which God do you mean? Did you say God or father?” At times she spoke of being in Heaven and that God seemed to be God, doctor or priest. In this connection there were ideas of being under the power of someone, God, devil or father.
As is usually the case where strong interest is expressed in the father, ideas of the mother being dead occurred, although in the frankest form she reported them as dreams; for instance, one night she woke up screaming, said that she had dreamed that her mother was dead and her sister dying. That, in the psycho-analytic sense, this represented a removal of a rival, making union with her father easy, appeared in the statement that her father was dead, but that she had dreamed he had come to life again for someone else. When asked what she meant, the question had to be repeated several times, then she said: “My mother died, my father and mother had a quarrel.” There is more than a suggestion here of a difference in the significance of death, in so far as it concerned the two parents. The mother dies and remains dead, that is, she is gotten rid of. The father dies, but takes on a spiritual existence and comes to life again, a frequent method in psychoses for legitimizing the idea of union with the parent by elimination of the grossly physical.
There were strikingly few allusions to the plainly sexual. She spoke of being married to the doctor, and even went so far as to say that they belonged together in bed. On another occasion she called him “darling.” Once she reported that it was said that she was going to have babies and babies and babies. These references were, however, quite isolated, so that the erotic formed a very small part of her productions.
Delusions of death in this case were present, but distinctly in the background. She spoke quite frequently of being in Heaven. She also talked of being crucified. Once she said: “I died, but I came back again.” This last utterance was rather significant in that frankly accepted ideas of death were unusual; for instance, she would say sometimes, “I think I am in Heaven, again not. It confuses me, but I know I am in Heaven.”
In general, then, her ideas were, on the whole, not at all typical of any one manic-depressive reaction. Correlated with this was an unusual mood picture. The quietness and apparent apathy of the patient were interrupted by little bursts of emotion, and throughout the psychosis there was a colouring of perplexity. Distress and anxiety appeared not infrequently and always appropriately. The distress was usually occasioned by an idea of injury to others, as when she cried over the fancied accusations of drowning her husband and mother; or in connection with accusations of herself, such as when she reported “They called me a whore”. As has been stated, there was never any frank elation, but an element of pleasurable expansive emotion was frequently present in connection with her religious utterances. This came particularly when she spoke of union with her father as God. She seemed to swell with ecstatic emotion. It was especially well marked once when she threw herself on the floor, and when asked what she was trying to do replied, “I want to do what God wants me to do, drop dead or anything at all”.
Perhaps the most unusual emotional reaction was a blocking, which occurred when certain topics appeared. One got the impression that ideas tended to come into this patient’s mind which were painful enough to disturb her capacity for connected thought. A good example of this reaction was when she was speaking of her father having died and coming to life again. On being asked what she meant, she became quite blocked, and the question had to be repeated several times, when finally the apparently unrelated statements appeared: “I dreamed my mother died—they had a quarrel”. Who had a quarrel? she was asked, and replied, “My mother and father”. Apparently her thinking about her father coming to life for someone not her mother stimulated deeply unconscious ideas concerning the separation of her mother and father, and her taking the mother’s place, and these ideas were sufficiently revolutionary to upset her capacity of speech for the time being.
She recovered completely about six and a half months after her admission.
