VOL. I UNGRADED JUNE, 1916 No. 11 Entered as second-class matter March 28, 1916, at the Post Office at Concord, N. H., Signed articles are not to be understood as expressing the views of the editors or publishers EARLY MANIFESTATIONS OF MENTAL DISORDERS DR. AUGUST HOCH PROFESSOR OF PSYCHIATRY, CORNELL UNIVERSITY MEDICAL COLLEGE, AND DIRECTOR OF THE PSYCHIATRIC INSTITUTE OF THE N. Y. STATE HOSPITAL Mental hygiene has many points of contact with hygiene in general, not only in the sense that the bodily condition, naturally, reflects upon the mental state, but also in the sense that in the prevention of insanity a considerable portion of our task does not belong, strictly speaking, in the realm of mental, but in that of general, hygiene. It is necessary to constantly repeat that insanity is not one disease but a comparatively large number of diseases or disorders which differ widely, not only in their manifestations but in their causes; so that in everything which refers to the practical dealing with treatment and prevention we have to follow quite different principles in the different kinds of diseases. In some of these diseases we are dealing with plain physical causes or conditions, such as syphilis, diseases of the blood-vessels, the premature wasting of brain tissue in advanced years, or we are dealing with alcohol or other poisons introduced into the body. The prevention of some of these diseases which, in part at least, have clean-cut causes, is theoretically simple and the task before us clear enough, as clear as it is, for example, in tuberculosis. That, nevertheless, even in these disorders the task is a difficult one, is due essentially to such human factors as ignorance, selfishness and prejudice. When I was asked to write on "Early Manifestations of Mental Disorders," I took it for granted that what was expected of me was not to deal with the early manifestations of the diseases we have just mentioned, diseases to which we are in the habit of applying the term "organic mental diseases." In the first place, these diseases occur essentially in the second half of life, and are therefore of less immediate interest to the teacher. But there is also another reason. In these organic mental diseases, just mentioned, the early manifestations of insanity stand in a different relation to the development of the disorder, than do the early manifestations in another group to which I shall direct your attention more particularly. In the organic mental diseases the early manifestations are much more an integral part of the disease; they indicate the beginning of the actual breakdown, they represent the first indications that a severe brain disease has started. On the other hand, in the other group of mental disorders we find frequently, even in early childhood, or at the age of puberty, or during adolescence or later, here and there certain peculiarities of character, certain defects of self-management which we must regard as danger signals and which should be taken much more seriously than is commonly the case. Such evidences psychiatrists have learned to recognize, above all, through careful inquiries into the life histories, the characters, the habits of those individuals who are brought to us after the mental breakdown has occurred. And the conviction has more and more been borne in on us that the public and, above all the physicians have not paid enough attention to such signs, and that a better knowledge of these early danger signals should be useful to all those who have to deal with children and young people. Of course one might ask then, whether we have a right to speak of such danger signals as early manifestations of insanity at all. It might be said that these are essentially defects of constitution, of make-up, of habits, and moreover, defects which need by no means always be followed by insanity. And it might further be said that, in treating of these more particularly, we are really not talking on the subject which was announced. But whether or not we should regard such signs as true early manifestations is after all a purely academic question which sinks into insignificance beside the essential question, namely; what is of practical importance? and from that point of view it seems to me that these earliest signs deserve more particularly to be pushed into the foreground. However, they undoubtedly represent unhealthy ways of living, and, though they may be, and undoubtedly are in part, the expression of a poor endowment, there is, we are convinced, much in them which, through better understanding, through the fact that our attention and our studies are directed to them, we shall learn to manage better. While there has been a certain tendency, on the one hand, to disregard these earliest manifestations of insanity, there has also been, on the other hand, a tendency to emphasize unduly heredity and degeneracy as unalterable factors in the individual which leads to a somewhat fatalistic sizing up of the situation. There is much which goes to show that such a view is onesided, and we hope that the future will definitely prove that it is often unnecessary. Two ways are open to treat the subject in hand. Either we might give you a summary of observations which have been made in regard to these earliest signs of lack of mental balance, or we might briefly consider some concrete instances, some living examples of individuals, some life histories which illustrate definite defects which were present for years or throughout life, and which show clearly that the breakdown did not come out of the clear sky but was rather an eventual outcome of inadequate self-management or inadequate management by the environment-to be sure, in addition to a certain weakness inherent in the individual. I shall choose the second course, and briefly make you acquainted with some actual observations. The first patient is a young woman, about whose early life we are fairly well informed. We are told that even as a child she was hard to manage and took advice badly. While I cannot find any very concrete examples or instances under which this behavior showed itself, the notes give enough to show that the difficulties which the parents and teachers experienced in managing the child were not due to any very active traits on the part of the latter, not to that kind of boisterous childish vivacity which is seen in normal children who are hard to manage; but rather to a passive resistance. She got along pretty well when left alone, but even simple adaptations were difficult for her. Thus it troubled her when her things were touched, or when she was interfered with in any way. Her reaction then to such interferences was, however, again not an aggressive one from which a certain healthy shaping of the situation might be expected, but a rather fruitless irritation, and more particularly, as is stated, a "going off by herself." Again, and quite consistent with what we have said, we are told that she played little with other children, was apt to cry when things did not go just her way, and then left her playmates. It is also specifically said that she was not liked by others. Children have a quick appreciation of barriers which another child, or for that matter an adult, erects about him, and shun that kind of personality. In company she was silent, took no part in what was going on and very often left the room. She seemed ill at ease and bashful. But she was not stupid, on the contrary rather above the average in intelligence, and she worked hard at school and had good marks. At 16 she became overreligious, a change which was not accounted for by anything that happened in her environment. Then came a year at business college which, so far as the work was concerned, was also passed satisfactorily, though her general traits did not change. But when the time came to use her knowledge, that is, to change from a more receptive situation, which makes infinitely less demands than the much more difficult task of stepping out into the world of responsibility, then she was unprepared and shrank from it; instead of taking positions which, evidently, under the force of example and promptings from home she did seek for a time, she found fault with every one, remained inactive. She married at 18, and after the birth of the first child developed a serious mental disorder, from which she has not and will not recover. A somewhat similar situation is seen in the following patient, though here the gradual changes are more plainly shown. This patient is described as a girl who was also shy and retiring, inclined to be afraid that what she did she did not do right, afraid that she was not obedient enough and she was apt to tell other children to be more obedient. Though she had the opportunity, she did not play much with others but preferred to be by herself, and somehow she was always unable to get into real contact with those about her and to derive satisfaction from this. Yet she, too, was quite intelligent and good at school. When puberty came on, with its physical changes, she was unable to take this naturally and had warped ideas about it. At 15, though she continued to look healthy and was a rather strapping girl, she began to sleep badly and appeared more absorbed. She also became faultfinding, dissatisfied; and even when changes were made according to her wishes, this did not bring satisfaction and she could not be aroused. This had been the case during the summer. When she went back to school it was soon found that she worked badly, but it was months before the mother made inquiries at the school and then she was told that the child acted funnily, got rattled, and was the laughing stock of the class. She was taken home. Then attempts were made to divert her by taking her to parties and theaters which, however, in her condition did not improve matters. Again some months passed without any one suspecting anything more serious, until suddenly she made a strange remark. But this was soon forgotten, and when vague thoughts and quandaries appeared about the meaning of life and death, about the universe, and so on, they were not regarded as especially important or strange in a 15-year-old girl. However, the catastrophe was now not very far off. After awhile she suddenly turned against her mother, spoke of the devil being after her, and finally got into a state of frenzied excitement. When she was finally brought for treatment she was in a stupor-like state in which her interest and her contact with the environment were extremely interfered with, a state in which she had completely turned inward, so to speak, and from this she has never and will never emerge. Somewhat different is the following case, that of a girl whose early history presented nothing very striking. It is said, however, that she always objected to control of any sort, but she got along fairly well until some six or seven years before the marked mental symptoms appeared, that is to say, she got along moderately well until her nineteenth year. At that time she went to a Normal school. There she was moody and unnatural, was given to all sorts of fads about her diet, which is always to be looked upon with some suspicion. She felt tense, complained of cold feet and of various digestive disturbances. In order to escape this, as she herself says, she lived a rather dissolute life for a time but, of course, without getting any real satisfaction from it. Later she began to study music but developed again what was called neurasthenia, was dissatisfied, uncomfortable, tense. Again, she made faddish attempts at treatment, this time by all sorts of absurd relaxation exercises which of course did not go to the root of the matter, and at the same time she lived in an environment in which vague thoughts prevailed, while balance and robust common sense were lacking. Suddenly the outbreak came when she proposed to a man whom she knew but slightly. She rapidly lost weight, thought she was married, and her conduct, in other ways, was absurd. |