RC T5 liiulogy 1 UC-NRLF B 3 lib 3fil en •X) 00 o MENTAL DISORDERS Briefly Described and Classified WITH A Few Remarks on Treatment and Prevention By CHARLES B. THOMPSON, M. D. Medical Director of the Mental Hygiene Societj' of Maryland Assistant Dispensary Psychiatrist The Phipps Psychiatric Clinic, The Johns Hopkins Hospital Baltimore WARWICK ^' YORK, Inc. 1920 -V- ' •-•• v*: ; ••' .•,'./ file -^v, £J -t.. -V CONTENTS THE TWO TYPES OF MENTAL DISORDERS A. Those associated with physical or chemical injury to brain tissue 5 B. Those which seem to exist only on psychological bases 5 A. MENTAL DISORDERS WITH DEFINITE INJURY TO BRAIN TISSUE L PHYSICAL INJURY— ORGANIC BRAIN DISEASE— Loss of Tissue. 5 1. General Paresis .^ 5 2. Traumatic Disorders ISORDI;KS II mentality ccjnivaler.t to that of a child between three and eight years of age; morons, still higher but still of subnormal mentality, namelv that of a child of eight to twelve years of age. It is quite evident that people who are thus Feeble-minded or Mentally Defective can never have the same sense of responsibility, judgment, memory or efficiency as a normal person of the same age. Yet they are still allowed at large because they have "always been that way," and they work untold harm, having to be always supported by others, raising large families of the same shiftless kind, frequently turning to crime for a livelihood. A large part of the daily work of the police force and jails is taken up with these mentally defective and hence irresponsible crimi- nals. Their irresponsibility and immorality and illegitimacy cause them to be an ever growing menace. Many diseased prostitutes are re- cruited from this class. 12. CONSTITUTIONAL INFERIORITY. May or may not be allied to above. The old-fashioned term "atavist" would come under this caption ; also the typical "bad egg'' or "black sheep" of the family. Applied to those from whose heredity and social status one would expect much, but who really seem lacking in moral and ethical sensibilities, and commit all manner of indiscretions, even crimes. This classification is often used to include the feeble-minded as well. The patient, who was a young man of good family, aged 23, was said by his father always to have been "slow" in school, and in fact never had passed the sixth grade, leaving at the age of 16. He had always been different from his brothers and from the rest of the family who were successful financiers and factory owners. Moreover, he was headstrong and self-willed and hostile to advice, but could never make his own living. At 18 he was sent South to work in a small town, but here he would con- tinuall}^ get into fights with the men he had to deal with or take orders from. Besides he w'ould drink and try to shoot up the town, trying to subdue all the toughs in all the barrooms, though he himself was only the size of a weak 14- year-old boy. From here he was brought back to New York. He gave up drinking and became a street-corner missionary. But he "preached Hell so hot" that the other missionaries had him removed. Then he married a girl of no greater mentality than himself, and was moved off to a nominal job in another city, and was lost sight of. II. Psychoses of Chemical Injury to Brain Tissue — or Toxic Psychoses. I. alcoholic psychoses. Alcohol, as a toxic drug, causes so many and such characteristic men- tal disorders that it is here given a place to itself. (a) Pathological Intoxication Drunken furor, the type in wdiich a man fights, beats his wife, mur- ders, sets fire to houses, and usually has no memory of the events afterwards. t2 MENTAL DISORDERS The patient, a man of 42, a constant drinker, came home one night evidently very drunk, and apparently extremely angry. He battered and pounded on the front door as he was opening it. He cursed his wife and called her obscene names. He picked up chairs and tables and smashed the other furniture and mirrors with them, cursing at his wife the while, and hurling the fragments of the furniture at his children. He finally upset the kitchen stove, bringing down the pipe, and scattering the cooking vessels and the supper all over the kitchen, roaring all sorts of broken bits of drunken obscenity. At the police station the next day, he apparently had no memory of this event, (amnesia). He said that he remembered coming home, but nothing more. He indignantly denied the violence, and told the judge that, although he drank frequently, he" rarely became intoxicated, and never to the extent described. (b) DeUriuui Tremens Generally comes after the patient has protracted his debauch until he can no longer eat or sleep. No sleep and no food plus alcohol form a disastrous combination. The characteristics are loss of sense of present situation and persons; and at the same time the patient imagines he sees and feels rats, mice, snakes, and other small animals, generally black, crawling all about the floor, the bed, the walls, himself. Often he is haunted by faces of the dead, or by a vision of the devil. There is a very marked appearance of fear — the. patient seems to be in the most horrible mental torture. Recovery generally takes place unless other complications are present. (c) Acute Hallucinosis Is not quite the same as delirium. The patient knows the date, where he is and the persons about him. But he imagines he hears threatening or slandering voices, or he may see terrifying sights — thinks the walls are falling in on him and he imust hold them up ; or - that a team of horses is about to run over hhn, etc. Often with a sardonic humor that causes him to lavigh at the same minute that he is shuddering with fear (Galgen-humor) ; great mental anguish. The whole hospital was aroused one evening by the sudden yelling of a patient who had just come in the previous afternoon. When he was inter- viewed he said that he had suddenly seen a team of two large, black horses which were just about to run over him. He was an alcoholic and had just begun to drink more heavily. He had been having similar terrifying hallucinations for the past two days. (d) Alcoholic Constitution Habitual alcoholics become increasingly inefficient and unreliable. There is both an intellectual and an ethical deterioration. Profuse promises are made but never kept. Forgetfulness develops often with precocious senility. Also suspicious states leading over to (e) Alcoholic Paranoid States Ideas of jealousy, persecution, or poisoniuii. In the Delusions of Jealousy, a man will accuse his wife of infidelity, and will cling to this idea in spite of all evidence to the contrary, openly accusing her of going with other men. Not infrequently he will kill his wife when in such a disordered mental state. ]\Iany murders have been committed on this delusion as a basis. MKXTAL DISORDERS I3 Delusions of Persecution and Poisoning The patient thinks that people are definitely against him to work him injury-^much like the usual Paranoia, except that here there is a definite alcoholic history leading u]) to the psychosis. It is a question if there is not the same mechanism underlying both forms. For we know that many cases of Paranoia represent a sub- merged homosexuality which is denied to consciousness. In other words, the fear is born of repressed desire. xA.nd the chronic alcoholic manifests his homosexuality through this channel, not admitting it to further consciousness, and not being able to ignore it completely. The patient — a chronic carouser — had been married several years. He had three children. One day he accompanied liis wife to a doctor's office, and there he waited in an outer waiting room while she was being treated for varicose veins of the leg. As the doctor and patient's w'ife emerged from his office, the doctor handed her her garter. The patient inferred from this that the doctor had had improper relations with her. He mentioned this many times to her. Also, he implicated the parish priest. The man threatened to kill his wife and the doctor, saying that he felt fully justified in doing so, and didn't care what hap- pened to himself. This man. also, no matter what jol) he held, sooner or later concluded that some certain man on the job was against him or trying to get him discharged. Thus both forms of the paranoid or delusional state were found in one patient. Abundant evidences of submerged or unrecognized homosexuality were shown in this man's record. (f) Korsakoff's Psychosis Loss of sense of date and place, great "holes in memory," with a compensatory lying to fill in. Connected with nerve injury, causing toe drop, etc. FinalW alcoholism may be merely a symptom of some other under- lying mental disorder. A psychopathic patient readily takes to alcohol as a stimulant or refuge in a state of depression, or in case of inefiiciency such as Dementia Precox or General Paresis. 2. DRUG PSYCHOSES. All other drugs besides alcohol may also figure in drug habits. (a) Drug habits may be regarded at times as a symptom of abnor- mal mental states or of an abnormal constitution. The craving for the drug seems to outweigh all other considerations whether of duty, policy, responsibility, or consideration for others. This results in ex- tremes of unreliability as regards his outward behavior. Any drug may be thus used — opium, morphine, cocaine, heroin, chloral, ether, chloroform. In seeking the efifect of these drugs, the patient seems to be trying to escape from unpleasant thoughts or situations of strain which trou- ble him in moments of introspection, or which seem to hover on the margin of consciousness. These painful ideas multiply as his dissipa- tions continue, so that to the unpleasant thoughts or mental conflicts which he originally sought to escape, are added the consciousness of 14 MENT-AL DISORDERS responsibilties shirked, promises broken, friendships violated, dutiei^ demanding to be met. In short, he has beset himself with added dif- ficulties of his own making so that the only spot of pleasure he finds 4s this drug which he seeks more and more. This is the reason why the habitual drug user is not apt to give up his drug, but rather to become ten times more an addict with each dose he takes. The psychological side of alcoholism, as well as other drug psychoses, is taken up in more advanced works. The *'habit" is rather the result of a disordered personality which remains constantly out of adjustment, and represents an evasion of the conflict in his mind, or living a lie. The addicts are hence constitutional liars and their consequent undependability and ethical deterioration are only to be expected. Perhaps the individual prefers this combi- nation to the discomfort of straightening out himself and the whole situation. Many interesting stories have been written pertaining to the state of mind of these drug addicts. (See "Spy Rock," by Henry \^an Dyke, "Confessions of an English Opium Eater," by DeQuincey.) (bj Conditions resulting from accidental poisoning with these drugs. These generally show comatose conditions (very heavy, deep sleep from which the patient can only be momentarily aroused) or deliria — patient loses knowledge of where he is, "wanders in his mind,'' sees things, hears voices, imagines he is in very exciting situations, etc. fe) Trade poisojiiug This may be accidental poisoning, acute or chronic, with manifesta- tions as above — coma, or delirium, or excitement. (d) Illuniinating Gas Poisoning Sometimes when a very great amount of the gas has been inhaled, the patient after resuscitation is found to have great inpairment of memory. Onl}- the most simple and usual things are remembered, thinking is largely abolished, and ambition gone. The mental horizon seems limited to the gratification of hunger, sex desire, and desire for sleep. Physically he is well and may live for years in this animal state, the brain injury being permanent. (e) TJiosc caused by food The most comimon is the caffeine psychosis in its mild forms, caused b\- over-use of tea or coft'ee. It is characterized J)v restlessness and impatience, desire to be on the go. dropping one half-finished task to take up a new one, insomnia, and sensibility to slight sounds and colors. In fact all sensibilities are much more keen and react to much finer stimuli than normally. This sensitization is the reason why cafifeine, in the form of coffee or tea, is so extensively used. It makes one feel more alive, more awake, more keen. Fatigue is correspondingly quicker in arriving, or if not, then when it does arrive is felt in much greater proportion. MENTAL DISORDERS 1 5 Also to be mentioned are F^ellagra, and Ergotism, acute poisoning — confusion or coma. Chronic (from ergot growing on rye) — depression, drowsiness and weakness, sometimes convulsions. 3. Mi:.\T.\L DISORDERS COMING FROM FEVERS (i. e. INFECTIONS), FROM POISONS OF VARIOUS DISEASES, OR FROM EXHAUSTION- THE TOXIC-INFECTIVE-EXHAUSTIVE GROUP. These are usually considered together because the results of infection are due to toxine and exhaustion also. (a) From fevers and Infections Commonest is delirium, slight lapse from normal; surest recovery. Disorientation plus hallucinations are the characteristics of delirium. A single woman of 34, whose past history shows a somewhat labile psychc- pathic disposition and a tendency toward slight depression, began to show signs of abdominal involvement — pain in the groin, tenderness over right lower quadrant, septic temperature, and sweats. The appendix was operated, but the signs continued. Eleven days after the operation she l:;ecame fretful and excited, and soon began to have visual hallucinations — thought people were looking through the ceiling at her; that the house was on fire; that a man came and dragged her about by the hair each night. , She thought the hospital was her home, and that she was in her own bed. She gave the month as April, whereas it w^as January. Immediately on examina- tion she warned the doctor that there were people standing behind him to kill him. She was easily recalled by a word or two from these. Hallucinations plus disorientation indicated the presence of Delirium. During the "Spanish Flu," or more properly Pandemic Influenza, there were many cases of mental upset wdiich seemed due to the ex- treme virulence of the toxine. A very excited form of delirium was a frequent complication of the disease. The patient was quietly lying in bed on the hospital porch which fortunately was screened. He suddenly jumped up and yelled, "Police, police. Send a police over here." To the crowd who immediately assembled in the street outside, he 3'elled, "They are trying to shanghai me here and send me away on a ship. Tve got the Spanish Flu. Send a police here." Other patients would get up and try to wander about or riui out of the hospital, not knowing where they were. These excited cases usually had a fatal termination. Depression and fatiguabilitx' seemed to be a common result of the infection, often lasting weeks. After the pandemic many cases were referred for examination whose disorder was said to have been caused by the Spanish Influenza. Certainlv many of these might merely have been irupending and were immediately precipitated by the infec- tion. Certainly, also, no such drastic toxine as that which characterized the severe cases of the "Flu" would leave a person quite unscarred. Depression with Fever or Infectious. In certain cases of grippe the patient seems to have delusions of persecution and to think he or she is mistreated. l6 ' , MENTAL DISORDERS Transitory Memory Defect may sometimes result. A Permanent Memory Defect is less common but has been known to follow Typhoid or Scarlet Fever. (b) Toxic-B^'haustwe Conditions, no fevers present, from Uremia, Diabetes, or Eclampsia, (toxic condition caused by pregnancy). Usually is just a deep coma. Or there may be delirium. Or accom- panied by some confusion. There may be great restlessness or irri- tability ; the patient may wander off and arrive in another city not knowing where or who he is. The various laboratory tests known to medicine will serve to differentiate and diagnose these conditions. THYROID. Cretinism. Congenital absence of gland — The child is born an idiot with characteristic appearance of thick lips; protruding tongue, dull expression and coarse, dry skin. The patient improves and becomes almost normal on being treated with the gland, continually slipping back into idiocy with cessation of the treatment. Hyperthyroidism — "Grave's Disease'' — comes from over-activity of the gland, and is much like the caffeine psychosis in its symptoms. Patients are generally "worriers"; worry over everything, are ap- prehensive, easily excited, sleepless, easily exhausted. Show rapid heart and breathlessness. It is both toxic and exhaustive in nature, the patient's muscles have less actual power because of the toxine. Hypothyroidism — from underactivity of the g"land (also called Myx- oedema) . Patients on the contrary to the above become lethargic, dull, stupid, forgetful, inactive. They tend to become fat and pale and doughy looking ; they always feel cold and sleepy. (c) Exhaustive — from Extreme Loss of Sleep. InalDility to grasp what is told, or remember ; loss of ambition ; irritability. There may be delirium. Exhaustion plus pain, especially in the old, often leads to delirium. A man of 72, a bookkeeper, always a hard worker, met with a fracture of the clavicle. This necessitated wearing a large plaster cast which was very uncom- fortable, especially as it was hot svunmer time. The heat, the discomfort, the loss of sleep, the pain from the fracture were the factors. He began to become confused and forgot where he was. then would be taking part in imaginary scenes, that is, became delirious. He was brought to the hospital and the procuring of rest and easing of pain finally resulted in recover3^ DEMENTIA FROM LACK OF SLEEP MAY OCCUR. There seems to be a suspension of judgment and self criticismi and regard for consequences, the patient may be easily suggestible and commit wild acts and even crimes, DISORDERS SHOWING FEATURES OF BOTH A. AND B. (l) THE PSYCHOSES OF PREGNANCY Are not a separate entity and are treated of in various parts of this syllabus, but in response to request, they have been here gathered into one group. They are of three kinds : MENTAL DISORDERS IJ (a) Toxic, or more properly Toxic-Infective-Exhaustive. (b) Psychogenic — entirely of psychic origin. (c) Combined Type — showing symptoms of both the above two types. (a) Toxic-infecti