The Diagnosis of Adolescent Mental Conditions, with special reference to Delinquents
Dr Morton Prince C. H. L. Rixon, M.D., M.R.C.S., L.R.C.P., D.P.M. Medical Officer, H.M. Prison, Brixton.
In the work of a remand prison the diagnosis of mental conditions is of con- siderable importance. When there is reason for the opinion that a prisoner who is on remand or awaiting trial is insane or mentally deficient, it is important that the court should be informed of this fact, as it is undesirable for several reasons that he should be convicted and sentenced to imprisonment. He would prove unsuitable for ordinary prison discipline, and probably unable to perform prison labour, and would almost certainly require after conviction that certification which could more properly have been effected before. At the prison to which the writer is attached some 8,000 or 9,000 male prisoners are received annually, either on remand, or awaiting trial at various Quarter Sessions or Assizes, and of these several hundred are remanded in order that their state of mind may be the subject ?f medical investigation.
When an undoubted case of insanity is encountered e.g., well-marked dementia paralytica with the characteristic mental and physical changes the diagnosis presents no difficulty and the course to be adopted is quite clear. Experience shows, however, that cases of an undoubted type such as this are in a marked minority in prison work, by far the larger number being in an early and undeveloped stage. A little consideration shows that this is what one might “This paper is published by permission of H.M. Prison Commissioners, but it must not be taken as necessarily representing their views.
expect, since the pronounced and obvious case soon comes into the hands of a psychiatrist, is certified, and placed out of harm’s way. It is especially the early case that is chiefly seen in prison work?the case which has not sufficiently attracted the attention of his relatives to cause them to seek advice on his behalf before he has committed some act which brings him into conflict with the law. These early cases are, naturally, just those in which diagnosis is most difficult. In many of them it is not easy to decide whether certifiable insanity is present at all. The following is an example of this type of case :?
Case 1, male, aged 51, was charged with the attempted murder of a colleague. Evidence given in court showed that the accused had followed his victim into the office of the works where they were both employed, and when inside had threatened to shoot him ” stone dead.” This was regarded as a would-be jest until the prisoner was observed to be loading a miniature rifle. Seeing this, his intended victim rushed out of the room and up some stairs, followed by the prisoner who, when he again caught sight of his quarry, fired the weapon at him. Fortunately nobody was hit, and the assailant was seized and disarmed. When he was brought into court he was remanded to prison for enquiry to be made as to his state of mind. When interviewed, the prisoner stated that he bore his would-be victim no animosity, and he would assign no reason for his attack on him. The two men had always been on good terms until a week before the offence occurred.
There had then been a minor quarrel about some surplus stock which prisoner had in his store, but it was apparently a trivial affair, and their relations with each other had been quite pleasant since. There was no family history of insanity, epilepsy, intemperance, or crime. The prisoner had always borne a good character hitherto, was trusted, and had worked with his ” mate ” daily for two years.
He got on well with all his neighbours and friends, and stated that he had no enemies as far as he was aware. No delusions were elicited, and no account of any hallucination could be obtained. He was mentally alert. Memory, Attention, Perception, Judgment, and Reasoning, all appeared to be quite normal, but he was observed to be slightly depressed. This was not, in itself, very surprising in view of the position in which he was. He denied any idea of suicide, and there seemed no reason to suppose that he was not speakng the truth. He had had no serious illness, no fits, no venereal disease, and was temperate in his use of alcohol. Physical examination was quite negative, except that a slight tremor of the hands was observed. He denied having felt any impulse to commit such an act on any previous occasion. Whilst under observation in prison his conduct was always normal, and his conversation was quiet and rational. The prisoner’s wife was interviewed, and she confirmed the account which he had given of himself. Three years before these events this couple had lost their daughter?a little girl of nine, who was drowned in a pond near the home?and the prisoner had been depressed then, and had sometimes seemed so since. On one occasion, a year before he came into the hands of the police, he got up in the night, dressed himself, went to the pond, and sat down there for a short time. He then returned home again. All idea of suicide on that occasion was denied, and his wife said that when he returned from the pond he seemed quite normal mentally. She had never had any occasion to think that her husband contemplated suicide, he had never spoken of it to her, and had never made any attempt. Except for the visit to the pond she knew of no instance of strange conduct. He was good- tempered, affectionate, and a popular man with his friends and fellow employees. Prisoner had an accurate and clear recollection of all the incidents relating to the charge, and there was no ground whatever for suspecting epilepsy. The only ” explanation ” of his conduct which he ever gave was that he was worried because his ” mate ” had wanted to act dishonestly, and to have him as an accomplice. A further remand, for more prolonged study of this prisoner, was granted, but no further light was thrown on the case. The court was informed that the accused was mildly depressed, and mentally unstable, but that he was not certifiable as insane. It then transpired that he had been the victim of sundry practical jokes at the hands of his workmates, and furthermore that the cartridge he fired was probably only a blank. The charge was reduced to one of common assault, and he was bound over.
As with insanity, so with mental deficiency, the diagnosis is sometimes fraught with difficulty. The Act of 1913 defines four classes of persons ” who shall be deemed to be defectives ” within its meaning. When certifying any individual as a defective, therefore, it is necessary to be certain that the case complies with the definition laid down in the Act. One of the commonest difficul- ties encountered in prison work is that of obtaining evidence that the condition has existed ” from birth, or from an early age,” as it must have done if the patient is to come within the scope of the definitions laid down in Section 1 of the Act. In addition to this difficulty in the diagnosis of amentia according to the statutory definition, that of distinguishing it from secondary dementia is almost equally common. The history has to be depended upon, and if this is unreliable or not clearly known, it is sometimes a nice point to decide whether the case should be dealt with under the Lunacy Act, or the Mental Deficiency Act. The following case illustrates both these diagnostic difficulties :?
Case II., male, aged 41, charged with begging, was remanded for medical examination as to his state of mind. There was nothing of importance in his family history, except that his father had died of General Paralysis of the Insane. Prisoner had had no serious illnesses or injuries, no fits, and no venereal disease. There was no evidence of alcoholism, and he had not been in the hands of the police previously. He was educated at an ordinary school and was in standard IV. when he left, but his attendance there had been very incomplete owing to domestic difficulties and troubles. He started work as an office boy and was later promoted to be a clerk, in which capacity he worked for two years. He was then a draper’s assistant for a time, but was stated to have developed religious interests, become a Roman Catholic, and concerned himself greatly in fasts. His conduct then became definitely abnormal, he threatened suicide, tried to starve himself, and threatened to kill his mother and sister. He was certified under the Lunacy Act, and was sent to a mental hospital, where he was detained for three years. After discharge from the hospital he was employed for a time in the confectionery business. He also learnt to drive a motor-car. When the “War started he was passed fit for general service?category A. 1?but, not wishing to serve in the army, he asked to see the Medical Officer again, and, on the ground that he had been in a mental hospital, protested against being made an A. 1 man. On this he was discharged and spent the period of the war serving in a restaurant. Since the war he had lived with an unmarried brother until a few weeks before his arrest, and latterly he had been living in common lodging houses, and supporting himself by selling matches, etc.
On reception into prison, he was correctly orientated in time and place, and not confused. His memory was found to be a little impaired, and he was noted to be somewhat childish. In the prison hospital he was reported to be disobedient, and sometimes insolent. He refused to make his bed, and alleged that he had been insulted and knocked about by other prisoners, and by the prison officers. His emotions were under but slight control, and he readily became excited, and Was equally easily depressed. He made foolish requests, e.g., asked if he could be ” spared the ignominy of going to the police court ” at the end of the remand period, and, when told that he would have to appear there, broke into tears. No delusions or hallucinations were elicited. He was rational in conversation and appreciated his position. There were no mannerisms, negativism, or flexibilitis cerea. Examination of his intelligence by the Terman scale gave a mental age of 10?11 years.
Prisoner’s brother, interviewed, said that as a youth he was perhaps some- what childish for his age, but he was considered normal until certified. Informa- tion was obtained from the mental hospital where prisoner had been a patient. The case had been diagnosed there as Congenital Mental Deficiency, and it was reported that he used to talk and act in a childish and fatuous manner. On the whole, however, he had behaved well and was finally discharged, after three years, as relieved.
A point to be noted is that prisoner had been certified under the Lunacy Act, as the Mental Deficiency Act of 1913 had not come into being at that time. Examination of this prisoner and his conduct whilst under observation in prison, both suggested secondary dementia, but the information obtained from the mental hospital made it clear that there was also an element of amentia. On the whole, it is probable that both initial sub-normality and a subsequent deterioration were factors in the case. Evidence to this effect was given at court, but the magistrate held that there was no evidence of the existence of defect ” from birth or from an early age ” on which it would be possible to certify under the Mental Deficiency Act.
Epilepsy is a disorder of adolescence which frequently presents diagnostic difficulties unless an actual fit is witnessed. This, of course, never happens when the patient suffers only from the minor form of the disease, and it is seldom that major sufferers are obliging enough to have a fit just at a time when it would present the physician with a diagnosis. Under these circumstances the history is of the greatest importance. In a very large proportion of the cases the disease first manifests itself before the age of twenty. Dementia paralytica is rarely seen so early in life, but hysteria is common. Convulsive hysterical seizures seldom occur when the patient is alone, whereas the epileptic fit is liable to erupt without regard to the patient’s spatial or temporal relations. The hysteric will not injure himself during his attacks either by biting his tongue or cheeks, or by falling against solid objects, or into the fire, etc.; nor will the sphincters be relaxed during the attack, though a quantity of pale urine of low specific gravity is sometimes passed soon afterwards. Hysterical convulsive attacks are commonly more prolonged than those of epilepsy, and there is a well-marked element of display about them which is not to be observed in the seizures of the latter disease. The mental attitude of the hysteric, moreover, will generally give a clue to the diagnosis, and, although complaint is made of ” fits,” it will be evident that the sufferer has little, if any, desire for them to be relieved, and is not really anxious or worried about his health.
When there is a history of fits starting in later life, search for evidence of dementia paralytica should never be omitted. Evidence of some mental deteriora- tion will probably be obtained in the form of failing memory, mental confusion, affective changes, e.g., elation, or grandiose delusions, or from the history which may be procured from relatives. The state of the pupils and their reactions, and the condition of the tendon-jerks and the plantar reflexes should be investigated, whilst tremor of the lips and hands, and the elision of syllables in speech and writing, should be sought for. Additional help may be obtained from the Was- sermann reaction, and the cytology of the cerebro-spinal fluid. A thorough physical examination, including that of the urine, should always be made when any patient complains of fits. In no other way can conditions such as uraemia and gross cerebral lesions be excluded, Finally, a point to be borne in mind is that fits which may be almost indistinguishable from epilepsy occur in middle- aged and elderly patients as the result of chronic alcoholism.
I he experience of prison medical officers has shown that epilepsy is relatively not a common cause of crime. Some text-books are apt to convey the opposite impression, and uninformed readers of them might be excused for thinking that, with most epileptics, it was merely a matter of time before some illegal act brought upon them the attention of the police. It is a common occurrence for a prisoner charged with an offence of some gravity to allege fits, but such allegations are made far more frequently than they are sustained, and even if a prisoner is an undoubted epileptic, his offence may be quite unconnected with his disease. The following is an illustrative case :?
Case III., aged 27, male, made a sudden and unprovoked attack upon a total stranger in a London park. The victim, a woman, noticed prisoner follow- ing her. Suddenly he made a rush at her and stabbed her in several places about the head and neck with a pen-knife, inflicting dangerous injuries. He then snatched a hand-bag which she was carrying, and which contained a few pounds in money, and ran away. Whilst running he was seen to throw some- thing into some bushes. He was chased by a police constable; but, after covering some distance, he turned round and attacked his pursuer, whom he stabbed three times in the neck; fortunately, these wounds were only slight. Two more constables then arrived on the scene and closed with the prisoner, who was finally knocked down by a blow on the head from a truncheon. He was taken to the police station, and the police surgeon who saw him there certified that he was able and fit to walk to the nearest hospital. He was taken there, and detained until the next day on account of a scalp wound caused by the truncheon.
Whilst there he refused to speak or to answer questions, although apparently fully conscious and comprehending. On discharge from the hospital he was brought into court by the police and charged with attempted murder. He then stated that he was an epileptic and had no recollection of the affair at all. He was recognised by the police as a man who had been convicted of larceny, theft, and assault, on three several occasions. At the place where he had been seen to throw something away a purse with money in it was found and this was proved to be the property of his victim. Soon after reception into prison on remand his statement that he was an epileptic was verified. He had had fits since the age of fourteen, and had been picked up in the street and taken to hospital suffering from injuries sustained in fits. He had been under the care of a well- known consultant at a hospital for epilepsy. His wife and mother were inter- viewed, and separately gave accounts of typical epilepsy, which accounts were confirmed by questioning the prisoner. He had never had a fit when in prison. Several points in this case indicated that the crime was not due to epilepsy. Although he had alleged that he had no memory of anything since entering the park until he found himself in the hospital, it was found that when questioned about this prisoner prevaricated, and made contradictory statements. He was |n need of money at the time of the crime, and when arrested had only threepence In his possession.
There was evidence that prisoner had followed his victim for a considerable distance until they reached a quiet place ; that, having stabbed her and knocked her to the ground, he had forced his hand into a vanity-bag which she was carrying and had taken out her purse; and that he had then walked away and ?nly started running when he saw the constable approaching. The constable Was a good runner, and was gaining on prisoner when the latter turned and attacked him. On his arrival at the police station he had been examined by 86 Mental welfare.
the police surgeon, who considered that he was not then in an epileptic state, and only sent him to hospital as a precaution. Whilst in prison awaiting- trial he was examined on several occasions and his replies to questions were frequently contradictory, and it was evident that many of his statements were untruthful. He had no fit during this period. At his trial at the Central Criminal Court evidence to this effect was given, and the opinion was expressed that the prisoner knew what he was doing, and that it was wrong. The charge was reduced to one of assault, and he now pleaded guilty, and was sentenced to three years’ penal servitude.
Every psychiatrist has met with cases of a puzzling indefinite type, which subsequent developments have shown to be Dementia Praecox. Probably no form of mental disorder is more elusive and vague in its early stages than this. There is a type of youth who spends all his time lounging in arm-chairs, and taking no apparent interest in anything. Very probably he refuses to get out of bed until the day is well advanced; he is idle, lazy, bad-tempered, and ill- mannered. He refuses to work, quarrels with all his relations, and is indifferent to the consequences of his supine conduct. A history such as this is not uncom- monly obtained from certain early cases of Dementia Prsecox. Relatives often like to think that such a patient is ” nervous,” ” sensitive,” ” highly strung,” etc., but are unwilling to think thatv there is any mental disease present, at any rate nothing ” serious,” and so a psychiatrist is not consulted until matters have reached such a state that those about him can endure the patient and his behaviour no longer.
In certain instances the matter is taken out of the relatives* hands by the patient committing some act which leads to his arrest by the police, and sub- sequently to a mental examination in a remand prison.
These cases sometimes arouse a suspicion of mental deficiency, owing to their habit of answering, ” I don’t know ” to very simple questions. When asked what day of the week it is the defective will very likely be unable to give the right answer. But the precocious dement, although he may say, ” I don’t know,” does really know, but cannot be bothered to think of the correct reply because he is too absorbed in his own reflections. When a case of this type is encountered it is very desirable to review the patient’s conduct as a whole. Idleness, trucul- ence, bad manners, and lack of initiative are too common for their occurrence to be of much significance individually, and it is only when they are regarded collectively that their importance can be fully appreciated. The diagnosis is plain enough in the presence of the classical signs of the disease, e.g., echolalia ?the repetition by the patient of words addressed to him; negativism?doing the opposite to anything requested ; flexibilitas cerea?allowing the limbs to be moved into any position, and keeping them fixed there; verbigeration?the frequent monotonous repetition of the same words, etc., but it can often be made before these appear by reviewing the patient’s past and present conduct, and by careful observation for evidence of hallucinations or delusions.
Patients suffering from Dementia Prascox are liable to commit sudden acts of violence upon slight provocation, sometimes, indeed, upon no apparent provoca- tion. In the paranoid form of this disease they may assign a delusional reason for this act, but in the hebephrenic type, when asked why they have acted thus, they will often give no explanation, except to say that they were annoyed, or that they ” felt like it.”
Case IV., male, aged 25, charged with assault, was remanded to prison for mental examination. Prisoner had gone on his motor-cycle to a petrol pump, and had asked the attendant to supply him with petrol. The man told prisoner to take his lighted cigarette away. Prisoner refused to do this, and continued smoking. The attendant refused to fill the tank, and so the prisoner loitered about the premises for some time, still smoking. When asked, politely, to stop smoking, owing to the obvious danger, he dealt the attendant a violent blow which knocked him down, and so injured his elbow that he was incapacitated for work for some weeks. Prisoner did not deny the charge, but adopted an attitude of indifference to the consequences. The only explanation he would give was that the man annoyed him. When he was fourteen years of age he had reached the top standard at school; then he had been a messenger boy in a shipping office for two years, and subsequently occupied a similar position elsewhere. He then obtained clerical work, and had several such posts, none of which he kept for very long. He left them of his own accord because ” he was fed up with them.” Seven years before the offence was committed he had an illness (? Rheumatic fever) which left him with chronic valvular disease of the heart, but his father stated that he was mentally normal until two years before his arrest. He then appeared to take no interest in anything, and became bad-tempered and truculent. When spoken to he often refused to reply, and spent his time in sitting about the house, doing nothing. Later he became quite unmanageable at home, and so his parents sought medical advice. Prisoner was certified and sent to a mental hospital. After twelve months there he was discharged on the applica- tion of his parents, to whom he appeared normal. He resumed his former habits, however, and had given endless trouble to his parents by the time he was arrested. When examined in prison he was found to be hostile, resistive, and negativistic. On being told to dress himself he would try to remove what clothes he had on. He refused to answer any questions about the period of his detention in the mental hospital. When asked what make of motor-cycle he rode he replied that he did not know, and his attitude was the typical ” don’t care ” and ” can’t be bothered ” type seen in Dementia Praecox. No delusions or hallucinations were elicited, he was not confused, and orientation was normal. There was some displacement of emotion, and he would laugh at the most trivial things, whilst usually he was surly and reticent. In the prison hospital he was found to be truculent and hostile to authority and discipline, and indifferent to bis position. He desired no occupation, but preferred to sit idle all day. He slept well. Measured by the Terman scale his intelligence was well above the average in spite of the small co-operation which he gave in the tests. There was no flexibilitas, and no echolalia or verbigeration. Although hallucinations were not admitted it was thought probable that they were present, as the prisoner sometimes appeared to be listening to something not audible to the examiner. Asked what he supposed the magistrate would do with him, he said he did not know. Nor, apparently, did he care. The court was informed that he was insane, and the case was dealt with accordingly.
Early diagnosis is important in all forms of disease; but in none more than those in which the disorder is mental. The sooner care and treatment is begun the better is the outlook for the individual, and the more efficiently is society protected against possible acts of violence and depredation, which would be criminal if the offender was of sound mind.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.