A Psychological Analysis of Three Delusional States
- Author:
Clara Harrison Town, Resident Psychologist at Friends’ Asylum for the Insane, Frankford, Pa.
The Belief in the Control of Thought from Without,In the Unreality of the External World, and in the Unreality of the Self.
There are three symptoms, which, though of frequent occurrence in the insane, have never been given an adequate psychological interpretation. They are intimately related psychically, as I hope to show in the course of my analysis, although they are not always found to be associated together in the same individual. These are:
The belief that one’s thoughts and feelings are guided and controlled by some outside power, whether this power be God, an electric machine, a malicious enemy or a hypnotist makes no intrinsic difference;
The feeling of the unreality of the external world, objective experience; and
The feeling of the unreality of one’s self, subjective experience.
Before attempting an analysis, I shall briefly describe a number of cases, which present these symptoms in various forms.
The first condition, the belief that one’s thoughts and feelings are controlled by some external agency, is well illustrated by the following cases:
Case 1.
A woman of refinement and culture, with a naturally
alert and inquiring mind, who, however, had not found any special field in which to exercise her mental powers. The conditions of her life forced her to be much alone, while they allowed her abundant leisure to do whatever her inclination dictated. Unfortunately, some of the popularly-styled psychological literature fell into her hands. This interested her greatly. She read it continuously, took it most seriously, and finally resolved to discover for herself whether it were possible to communicate with “the other world.” She put herself into a passive attitude and waited expectantly for the communications. She succeeded in securing them, succeeded so well that she would sit up night after night to enjoy this wonderful intercourse. She was told many delightful stories about all sorts of objects which happened to attract her attention, and at times her actions were guided by the advice she received. For instance, she was passing a shop window one day in which was exhibited a curiously constructed parasol. She was bidden to go in and buy it; she did so, although she needed no parasol, and was subsequently told a fanciful little tale about a Japanese lady who had made it. She could scarcely believe that her own mind conceived these tales, as they were in knowledge beyond her experience, and in literary quality beyond her ability. She believed that they were direct revelations from God. It is of interest to note that I was able to convince this patient that her revelations were merely products of her own mentality, and moreover to fill her with a wholesome sense of the clanger involved in encouraging, as she had done, the passive states of consciousness. I accomplished this by building up in her mind a rational conception of the mental conditions which led up to the experiences, to her so mysteriously inexplicable, and by minutely analyzing for her the experiences themselves. Case 2. This case is not unlike the previous one. The patient, a man, suddenly became aware that God was talking to him. All he had to do thereafter when he wished enlightenment on subjects in which he was interested, such as astronomy or electricity, was to lie back passively and attend to the ideas on the subject which God would send to his mind.
Case 3.
This patient was a woman whose mind teemed with delusions of the most vivid sort. Moreover, she experienced auditory hallucinations almost constantly. In every tick of a clock, creak of a shoe or chirp of a bird, voices were heard. These voices discussed with her questions of which she was thinking. Visual sensations also produced voices, and organic and tactile sensations were accompanied by words. Her hands, feet and all parts of her body talked to her, she experienced shooting sensations running the length of her fingers and believed that a thought wrote itself out there. “When she touched any object, words would come to her which she believed entered by telepathy through her fingers. She was commanded what to do and what not to do, and lived in constant dread of doing the wrong thing.
The passivity of most of her thought she recognized fully while still in the hallucinatory condition. She at that time argued with me that these thoughts could not be her own, as she had no control over them and as they were totally different from any she had ever experienced. She believed firmly that the thoughts were impressed upon her by telepathy, and further, that by the same means her thoughts were made known to others.
This patient made a complete recovery and I cannot but feel that it was hastened by her final acceptance of my explanation of the voices and her consequent persistent effort to keep thier mind actively engaged and to resist the inclination to adopt the passive, listening attitude. After her recovery she told me that she had never for a moment lost her power of reasoning, but that her mind was so taken up with the vivid sensations and ideas which were forced upon it, that there was continual war between her old self and these new experiences.
Cases 4, 5 and 6. These three cases are all young girls, and are all cases of dementia precox. They are all alike annoyed by organic sensations and unwelcome thoughts. One asks me what they mean and how we put them into her. Another thought for a while that Christ and the devil }vere contending for her spirit, and that the devil sent the thoughts which bothered her. She then had great faith in Christ, called herself His child and prayed to Him to help her. From that phase she passed into one where she cared no more for Christ, and now she considers herself a child of the wind, and believes that the wind puts the ideas into her mind. The sixth case believes the thoughts and feelings to be impressed from without, but does not seem to have formed any distinct idea concerning their source.
Case 7.
The seventh patient is a woman suffering from her third attack of melancholia. In speaking of her condition, she says that she is perfectly rational, but that she worries a great deal. This worrying, she claims, is beyond her control, as she is hypnotized and the worry put there. Case 8. Another melancholic woman believed her thoughts and will were controlled by a little child; and after the death of the child she felt that it must be the devil who guided them. Case 9. A third case of melancholia frequently makes remarks relating to her past life or the past of her friends. She afterwards begs us to believe that they are untrue (as they are), saying that the words come entirely without her wish, that she knows nothing about them and cannot understand it all. Case 10. Still another woman tells me that some people work on her mind from a distance with electric batteries and take her thoughts, her knowledge, and her will from her, using them as their own and gaining all the credit that is really her due, while she is left without her music, her songs, her Latin and Greek. The process, however, works both ways, and she gets the thoughts of these other people; she does not at all enjoy the exchange, and when writing a list of words for me she carefully omitted all those which came from some other source than her own mind.
Case 11. The next patient tells us that she is made to do, say and see queer things, that she has no control over herself, either in thought, speech or action. She asks whether I do not think it is the devil putting these ideas into her. Iler trouble being largely motor, she is compelled not merely to think but also to speak out her thoughts. It is interesting to note that she recognizes the enforced character of the utterance of the words, i. e., her own passivity, for she is persuaded that there is an electric machine in the room above her dragging out her thoughts.
Case 12.
I have chosen for the next illustration a young woman suffering from the maniacal form of manic depressive insanity. She says that she is continually talked to by the Holy Spirit. She explains that she does not hear a voice, but that the words are in her head just like thoughts, that just as we expect our thoughts to be heard in heaven, she hears the thoughts of God. When she wrote a list of words for me, she said that she was entirely irresponsible for what she wrote, that she did not know, when she started a word, what it would be, that her hand was inspired.
Case 13.
The thirteenth patient thinks her thoughts are controlled by drugs given by the physician. She says that she cannot think of things when she wishes, but only at certain times; and that all this is brought about by the action of drugs. Cases 14, 15, 16, 17 and 18. Five cases present conditions similar to those already described.
In illustration of the second symptom, the feeling of the unreality of the external world, I present the following cases.
Case 3 (above). To this patient the world seemed entirely changed. Tor months there were neither stars nor moon for her, and when she finally recovered, her surroundings were a wonderful surprise, they differed so completely from her previous idea of them.
Case 14
A woman to whom the world seemed to be in a state of perpetual confusion. The people around her appeared ill and changed and varied greatly in appearance from day to day. The trees, the sunshine, all looked strange to her.
Case 19.
Complains that not even the food is real,?the potatoes are not real potatoes, the apples not real apples, etc.
Case 20.
Believes that the biblical prophecy has been fulfilled, that there is now a new heaven and a new earth and that the people here have all died and risen again. “It is all so completely different,” she says.
Case 21.
Another woman was greatly bewildered by her surroundings. She volunteered:
“I don’t believe my eyes see as yours do.”
I answered that I believed she was right, but suggested that in order to make sure of it we both describe what we saw. She insisted that I do so first, and when I had finished she said,
“I seem to see the same, but it is different.”
I asked her on what she was leaning. She answered,
“It seems to be a bed, but I don’t feel that it can be. I think I am out of doors and far away.”
Case 22
This woman could not believe that the world anywhere was as it used to be. She was taken a long drive through parts of the country that she knew well, but even the children on the streets looked strange to her.
Cases 23, 24, 25, and 26
Four other women all complain that everything is altered and strange. The third symptom, the feeling of the unreality of one’s self, was manifested by several of the patients already cited. Case 3. This patient experienced great changes of bodily sensations. She at one time felt that she was embodied in a little pet dog.
Case 16.
This woman believes that her brain and soul have departed and that she is horrible to look upon. She does not wish people to see her on account of her frightful appearance. Case 24. Believed that her head had been removed and another one put in its place, that her teeth were stone and her body gradually changing to iron. She said she had no eyes and wondered that she could see; she felt that she was very, very small (she was a large woman) and every one else looked large to her in comparison.
Case 25.
Believes that she is no longer human, that her organs are all gone and that therefore she can never die. She also thinks that her face is entirely changed and that she is horrible to look upon. Case 26. Felt she was some one else; said she was not sensitive to cold or to weight. Case 27. Another woman with practically the same delusions as Case 25. On account of the greater simplicity of the processes involved, I shall describe the last two phenomena first, though, in point of fact they usually appear last in the development of an individual case, the more complex, volitional processes breaking down first
First we will attempt to reach an understanding, through an analytic description, of the feeling that the external world is unreal. When the adult human being experiences a perception, the experience is not so simple a phenomenon as one would at first suppose. For example, when a man who is accustomed to apples, sees one, or in other words has a perception of one, what is comprised in the experience ? He sees the color, size and shape of the apple, and over and above all that he sees, he knows it is an apple, that it is eatable, that it is rather hard, and he has also an idea of its taste, smell, hardness, etc. Now the first time that he saw an apple he knew nothing of its name, its use, its taste or its hardness; the appearance of the apple told him nothing of this. He knows these facts now only because he has experienced them formerly in connection with the sight of the apple, and its appearance now recalls them passively without the slightest effort on his part. When any two perceptions or ideas have once been experienced together in consciousness, the presence of one tends quite automatically to recall the other. Thus all our perceptions are enriched by our past experience, and this in a perfectly passive manner without the slightest effort on the part of the individual. Without this contribution from the past, the perceptions aroused by external stimuli would be very inadequate experiences.
The physiological explanation of these phenomena is as follows. The brain cells are all connected one with another by nerve fibres. When one cell is stimulated strongly enough, the excitation spreads to the surrounding fibres and cells. Each excitation of cells and fibres increases their instability so that they thereafter tend to respond more readily to stimulation. When two cells are stimulated simultaneously, the excitation from both cells spreads along the fibres connecting these cells, which are thereby rendered doubly unstable so that future excitation of either of the cells tends to spread along their connective fibres rather than in other directions. It follows that when one brain area is stimulated, the excitation tends to spread to those areas which have been frequently stimulated simultaneously with it. Each cell excitation is accompanied by a mental experience which recurs when the cell excitation is repeated, and in this way it happens that sensations, perceptions and ideas have the power of recalling other ideas which have been previously simultaneously experienced.
In many pathological subjects, the fusion of the new sensations with the recalled sensations and ideas fails to take place; there is a dissociation of the past and present experiences. In the language of the physiological theory, the excitation of certain centers does not spread to those centers formerly associated with them. Something arrests the purely passive associative process and the individual experiences only the group of sensations immediately aroused by the object. Thus every perception is a novel experience ‘for them, and the whole environment is strangely new each day.
To them the trees, the sun, the houses and people all seem changed. They tell us that we differ in appearance from day to day; and they are in constant anxiety because everything about them seems so strange and wrong.
The feeling of unreality in relation to the patient’s own body lends itself to a similar explanation?in fact it is simply a special phase of the same condition. In the condition just described sensations aroused by external objects failed to call up past mental experiences; in the condition under consideration, the sensations aroused by bodily movements and organic functioning fail to excite the associated sensations, with which they are ordinarily fused. When this fusion fails to take place, owing to a pathological disturbance of association, the patients are strangely aware of all their organic sensations. They stand out in consciousness distinct and isolate, and are not, as under normal conditions, merely undefined elements in the general coenesthesia. The organic sensations then seem queer and unnatural, and some patients develop from such experiences the idea that they are not human beings, as did Cases 25 and 27, cited above. These women both believe that they have no digestive organs, no circulation, etc., and in consequence that they can never die.
This theory bases the feeling of the unreality of the self, chiefly (in some cases perhaps solely), upon a defect of association in its most simple and elementary phase, that of the fusion of bodily and organic sensations with similar sensations secondarily aroused through the reflex functioning of the nervous system. The association process pathologically affected is a purely physiological one, and may be referred to the cerebral cortex but also to lower centers. The tendency among psychiatrists has been to find the explanation of the feeling of unreality in anomalies of sensation or in a dissociation between sense perceptions and muscular or organic sensations. Of late, however, the evident absence of sensory or organic disturbance in many patients presenting the symptom, and the presence of anaesthesias and profound circulatory disorder in many patients who do not present it, have led investigators such as Janet, Sollier, and Packard, to seek for a central theory. Janet inclines to the belief that the condition is due to a general lowering of cerebral activity, Sollier attributes it to a functional change in the cerebral cortex, and Packard to a defect of association.
The feeling of unreality often exists with reference to external objects without extending to the personality of the patient; it is also frequently expressed exclusively in relation to the subject’s self. One patient, Case 20, told me that the whole world had been changed in the last year, that there was a new heaven and a new earth quite different from the old, but that she herself, strange to say, was not changed at all, excepting that her voice was softer. Others find themselves strange and inhuman, but the world quite natural.
To reach an understanding of the first symptom, the belief that the thoughts are controlled from without, it is necessary to trace a little further the association theory. Each perception or idea has the power of recalling all other mental experiences with which it has been associated. It is quite evident, however, that it does not in any particular instance recall all others. In the course of ordinary experience each sensation, perception and idea has become associated with such a large number of others, that the limits of possible associations would seem to be set only by the limits of the past mental experience of the individual. The limit to the number of recalled ideas is really set by the limitations of the field of consciousness. Only a small number of perceptions and ideas can be experienced simultaneously, therefore only a few will be recalled; these will include those which fuse immediately with the sensation and make up the perception (which process has already been described) and one or more others, which have a more or less intimate connection with the perception, but are in themselves quite distinct. Just what these last will be is determined, on the one hand, by the recency, frequency and intensity of the previous existence of the recalled ideas and, on the other hand, by what factor or factors in the recalling idea act as agents of recall. If the recalling factor is simply the sound or visual form of a word, the recalled idea may have no logical connection with the recalling; for example, money may bring forth, bunny, funny, Monday or monotony. If, however, the recalling factor is an idea conveyed by the word or one of its elements, the ideas recalled will have some logical connection. To effect such logical associations, it is necessary that the recalling iden shall be interesting enough to hold the attention. The idea must dominate the consciousness. When the train of thought is determined by such a dominant idea the process is known as active apperception. It is always marked by concentration of attention. When there is no concentration on one idea, and the association process is let alone to bring forth what ideas it may, the process is known as passive apperception. This is merely a different phase of the process which results in the fusion of the new with the old in perception; the absolute fusion in perception being due to the fact that all the elements of the fusion had previously been associated together, and together localized in some definite external object or bodily part.
In the normal individual, thought is made up of both forma of apperception, sometimes one predominating, sometimes another. With some insane persons, however, the power to concentrate on an idea is so greatly reduced that the train of thought is made up almost entirely of such ideas as passive association calls into existence. All sorts of irrelevant and, what seem to them, extraordinary ideas come into their minds. They know that they have come without effort on their part, they recognize that they are quite different in character from their former thoughts as they remember them, and it is natural that they should conclude, as they usually do, that some external agency is responsible. Among the examples quoted above, three believe God to be speaking to them, three that friends or enemies communicate with them by means of telepathy, one that she is under the power of a hypnotist, two that they are acted upon by electric machines, while one and all realize that their thoughts are largely beyond their control. Although these patients are unable to guide their thoughts, which often proceed in leaps and bounds from subject to subject, associative connections can usually be traced throughout; the power of association remains intact, in fact a hitherto undiscovered ability and ingenuity in rhymes and other verbal associations often manifest themselves. The disturbance is distinctly not one of association, but is entirely the result of inability to control association and hold it in check by concentrating the attention on some one idea. It is a disturbance of active apperception caused by a failure of attention. In many cases this passive thought is almost continuous, and the patient can rest from the torrent of ideas neithor by night nor by day. This would naturally be expected, for with the loss of the power of concentration the power of inhibition disappears, as no idea can be held uppermost long enough or strongly enough to inhibit other ideas.
To reduce the study of the kinds of association used by the patients to experimental limits, I require them to write during fifteen minutes a list of words. They are asked to write continuously, and to write without hesitation whatever words first suggest themselves. The lists are then analyzed, and the associations found therein grouped into two large classes, the first embracing all those associated words which were suggested by the meaning of the recalling word, including judgment, contiguity, similarity, and sentence form associations, the second embracing all formal, mostly verbal associations, such as rhymes, sound associations, alliterations and associations resulting from speech habits. The first group with the exception of some sentence form associations represents active apperceptive thought; the second group and a certain variety of the sentence form association represent passive apperceptive thought, or simple association.
Lists of words were obtained from sixteen of the eighteen ? cases presented to illustrate the belief in the external control of the thought, and in all of these lists, save one, associations of the passive, superficial type predominate.
Briefly stated, the patients who believe their thoughts are controlled from without, are suffering from an inability to control their thoughts by dominant ideas, owing to a disturbance of active apperception, the result of a defect of attention. The patients to whom the external world seems unreal are suffering from an inability to recall past associations, when an accustomed sensation or perception is experienced; this is a disturbance of passive apperception. The patients to whom the self seems unreal are suffering from an inability to arouse by organic sensations those secondary sensations with which they are normally associated ; this is also a disturbance of passive apperception. The first defect is one of attention, a variety of aprosexia; the second is one of association, a form of amnesia, and may be called amnesic dissociation; the third is also a defect of association,?a physiological dissociation. Defects of association may exist without any derangement, of the active apperception. This is very evident in cases where the defect is limited to the fusion of sensations of one modality, say olfactory sensations, with their past associates. Such limited defects of association may exist without in the least interfering with the power of concentration, in which case active apperceptive thought is possible along all lines excepting those crossing the restricted association field. A total loss of associative power would of itself make all connected thought impossible, for concentration of attention would be futile were there no associated ideas through which to guide the thought. If, however, there is a loss of power of concentration in conjunction with the limitation of association ability, which is more often the case, the associations will be superficial in character within those fields where the association process is normal; beyond their limits associative thought will be entirely absent.
On the other hand, a derangement of active apperception manifested in a loss of the power of concentration, may exist without any defect of the associative process. In this case the result will be superficial and illogical associations, but not necessarily a reduction in the number of associations or in the rapidity of their recall.
The conclusion that a belief in the external control of thought is based upon a defect of attention, leads me to formulate certain definite methods of treatment. The problem is similar to, yet very different from that presented to all teachers of young children. The problem in both instances is that of training an individual who is deficient in the power of concentrating the attention. The cause of this deficiency, however, is quite different in the two cases. In the child it is due to a poverty of relevant and connected ideas; every object is of about equal interest to him and he presents a typical case of aprosexia, or flightiness of attention. The teacher’s task is to build up in his mind groups of related ideas, and gradually, as his stock of information increases, an interest in certain things will be developed, and the aprosexia will disappear. The insane patient incapable of concentration is not distracted as is the child by external objects and happenings, nor is his lack of interest dependent upon lack of knowledge or poverty of ideas. He has plenty of ideas, but is incapable of controlling, of regulating them; they, ‘on the contrary, seem to control him.
The task here is not to present new ideas but to re-preSent the old ones in such sequence that order will be reestablished. Some active interests must be built up for the patient; he must be given such employment as seems most suitable and such constant supervision that continuous and intelligent performance of the task will be assured. In several cases I have found it quite possible to develop in the patients an adequate conception of their true condition, and to convince them that its cause was not the control of their thoughts from without, but lack of control by themselves. They have not only accepted iny explanation but exerted themselves to assist in their own treatment by endeavoring to keep their minds employed in a way that would discourage passive unregulated thought.
The conclusion that the feeling of unreality of the external world is based upon a lack of power in the sensations to recall past associates is also suggestive of a certain line of treatment. The perceptions must be thoroughly rehabilitated for such patients. The ideas which the appearance of an object should recall must be drawn out by questions, or if this fails, the object must be presented to them through the different senses. This process must be repeated again and again until the group of experiences has become reestablished in the mind of the patient. This memory training is, however, less likely to succeed than the training of attention outlined above.
Still less hopeful is the attempt to treat psychically the feelin o- of unreality of the self. This feeling I have attributed to the failure of organic sensations to arouse the usual associations. If this interpretation is the correct one, a method of treatment to be successful must, wThen a certain organic or kinesthetic sensation is experienced, arouse in consciousness its accustomed associates. It is obviously impossible to do this by suggestion, as these associates are such obscure sensations that we are ignorant of their nature The only treatment that suggests itself is the physical stimulation, through drugs or otherwise, of the organic functions, with the hope that this induced excitation may, through diffusion, result in the arousal of those secondary sensations and other associations which have dropped out of the experience. Wliile my analysis indicates that what I have called physiological dissociation is the most likely cause of the feeling of the unreality of the self, it does not preclude the possibility of an amnesic dissociation being a contributory factor. Similarly the feeling of the unreality of the external world may, in some cases perhaps, be conditioned by a physiological dissociation. references to the literature.
TTofb ueust. A review of some recent papers upon the loss of the feelin^ of reality and kindred symptoms. The Psychological Bulletin, Vol. II No. 7. pp. 232-241. Fred II The feeling of unreality. The Journal of Abnormal rsicholofv, Vol. I. No. 2. pp. 00-81. Sollier, Paul. On certain cenesthetic disturbances. The Journal of Abnormal Psychology, Vol. II. No. 1, pp. 1-8. Tanet Pierre. The psyclioleptic crises. Boston Mcdical and Surgical Journal Vol. CLII, No. 4, pp. 93-100.
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