Studies in Forensic Psychiatry

That mental disorder may be due to causes purely psychic in nature is acknowledged by everyone. The older psychiatrists laid much stress on this point, a revival of which may be seen in the present-day widespread psychoanalytic movement. The reaction to the all too-embracing materialistic tendencies which have dominated psychiatric thought in recent decades was bound to come. It was especially the clinician who gave the impetus to this movement, because in pursuing the materialistic bent he found himself totally helpless as a therapeutist in the great majority of mental cases, and was therefore eventually forced to seek more promising paths.

Bleuler's attitude towards this question, because of the prominent position he occupies in the world of psychiatry, is interesting.

"Bleuler, who succeeded Forel as Professor of Psychiatry and Medical Director of the Cantonal Insane Asylum (Burghölzi) at Zurich, having become convinced that no solution could be arrived at along this anatomical path for the many riddles offered by the disturbed mental life, had for years chosen the psychological path. He was led to take this course because he knew that of the chronic inmates of the asylum, only about one-fifth showed anatomical changes of the central nervous system sufficient to explain the mental deviations exhibited."[1]

The results already achieved by this change of attitude in psychiatry are sufficient justification for its existence.

One became especially convinced of the potency of mental factors in the production of mental disease from the observation and study of the psychoses of criminals. Here the conflicts which lead an individual to seek in mental disorder a satisfactory compromise are so concrete as to leave no doubt concerning cause and effect.

Kraepelin[2] asserts that mental disorders occur ten times as frequently in prison as in freedom. The criminal, who in most instances is already burdened with a more or less strong predisposition to mental disorder, upon being placed in prison finds himself at once in a most favorable environment for a mental breakdown. It is true, imprisonment acts more deleteriously upon the psyche of the criminal by passion, the accidental criminal, but even the recidivist who would be expected to feel less keenly the painful loss of freedom, falls a prey to the deleterious effects of prison life. The unfavorable hygienic surroundings which are found in most prisons, the scarcity of air and exercise, readily prepare the way for a breakdown, even in an habitual criminal. Above all, however, it is the emotional shock and depression which invariably accompany the painful loss of freedom, the loneliness and seclusion, which force the prisoner to a raking occupation with his own mind, to a persistent introspection, making him feel so much more keenly the anxiety and apprehension for the future, the remorse for his deed, that play an important rôle in the production of mental disorders. This is especially true when it concerns an accidental criminal, one who still possesses a high degree of self-respect and honor. Imprisonment furnishes us with a great variety of mental disorders, the origin of which can be traced in a more or less direct manner to the emotional shock and influence upon the psyche which it brings about.

The psychogenetic origin of the psychoses of criminals can be established far more clearly in prisoners awaiting trial. Here the deleterious effect of confinement upon the physical health can be ruled out almost entirely, and the etiologic factor must be sought for exclusively in the emotional shock which the commission of the crime and its attending consequences provoke. The strong effect upon the psyche produced by the detection and confinement, the raking hearings and cross-examinations, and the uncertainty and apprehension of the outcome of it all are the factors that are at play here.

Reich,[3] in 1871, was the first one to call attention to the mental disorders of prisoners awaiting trial. He could observe the development of mental symptoms even during the first hours of confinement, and the relation between the psychosis and the emotional shock of the situation at hand could not be doubted. He describes this acute mental disturbance as follows:--"Already in the first hours or days after imprisonment, or soon after a severe emotional shock, a sort of psychic tension sets in. The prisoner becomes silent, chary of words, lost in brooding. He observes little that goes on about him and remains motionless in one spot. His face takes on an astonished expression, the gaze is vacant and indefinite. If he makes any movements at all they are hesitating, uncertain, as those of a drunken man. Vertigo and aura-like sensations appear; severe anxiety overpowers the patient, which with the entire force of a powerful affect crowds out all other concepts and sensations and dominates the entire personality. Consciousness becomes more and more clouded, soon illusions, hallucinations, and delusions appear, and the prisoner becomes especially taken up with ideas of unknown evil powers, of demons and spirits, and of being persecuted and possessed by the devil. Simultaneously they complain about all sorts of bodily sensations. In isolated cases one may observe convulsive twitchings of the voluntary and involuntary musculature. Finally severe motor excitements set in. The patient becomes noisy, screams, runs aimlessly about, destroys and ruins everything that comes his way. With this the disease has reached its height. At this stage consciousness is entirely in abeyance and the disorder is followed by complete amnesia." Reich supposes that this acute prison psychosis may be included in that large group of abnormal psychic processes, developing from affect and affect-like situations.

Reich's important work remained the only one on the subject until 1888, when Moeli again called attention to it. Moeli[4] spoke of patients in whom an apparent total blocking of all thought processes took place. They would exhibit complete ignorance of the most commonplace facts, would forget such well-known things as their own name, place of birth, or age; were unable to recognize the denominations of coins, etc. He noted, however, that although the answers these patients gave were false, they had a certain relation to the question. For instance, coins of a lower denomination would be mistaken for higher ones, postage stamps were called paper, etc. They also showed a marked tendency to elaborate all sorts of false reminiscences about their past life. Along with this failure of the simplest thought and memory activity, these individuals were otherwise well-ordered and behaved.

The reader will at once recognize in the above description the well-known Ganser symptom-complex, the several variations of which have been so frequently discussed of late years. Ganser[5] further showed that these cases frequently evidenced vivid auditory and visual hallucinations. At the same time there existed a more or less distinct clouding of consciousness, with the simultaneous presence of hysterical stigmata, especially total analgesia. After a short time recovery took place, the patients suddenly awoke as if from a dream and evidenced a more or less complete amnesia of the events which had transpired.

Numerous discussions concerning this disease-picture have appeared of late years in literature. The Ganser syndrome, or twilight state, has been enlarged upon, and several variations of this condition have been isolated. The chief contention, however, of the various authors on this subject seems to be whether this symptom-complex should be considered as hysterical or whether it should be placed among the large group of degenerative states. Both views are ably defended by prominent psychiatrists. I have recently observed the Ganser syndrome in an undoubted case of toxic-exhaustion psychosis.

Raecke[6] designated this disease-picture described by Moeli and Ganser as an hysterical twilight state in psychopathic individuals. These conditions were developed in them as the result of emotional excitement in imprisonment. The constant hearings, the confusing cross-questioning, the fear of punishment, finally the injurious effect of solitary confinement, shock and weaken the slight mental tension of the prisoner to a marked extent. As a result of this, we have on the one hand a condition of apathy, of inability to concentrate the mind, of incapacity to think and of a sort of feeling of being wholly at sea, accompanied by vertigo and other nervous manifestations, while on the other hand the physical despair, the obstinacy of the prisoner, now increase to pathological maniacal attacks, now again are changed to stubbornness, mutism, with refusal of food. At the same time the more or less constant wish to be considered sick, and in consequence to be freed from imprisonment (and in this we see perhaps the hysterical component), may influence deleteriously and in a peculiarly modifying way the disease-picture. The various questions put to the patient by the examiner may act as so many suggestions. Raecke further calls attention to the manifold similarities which these conditions may show with catatonic processes. In these hysterical twilight states, quite aside from mutism, negativism, and catalepsy, peculiar mannerisms were noted, a sort of affected, childish way of speaking, motor stereotypies, swaying of the head, running in a circle, queer actions, and sudden expressions of senseless word combinations. In a later work Raecke[7] describes a symptom-complex, which he designated as "hysterical stupor in prisoners", and in which the catatonic symptoms exist in a still more pronounced manner. The severe forms of this disorder, which may extend over weeks and months, are liable to be confused with progressive deteriorating processes, especially so because those symptoms which were wont to be considered by many as positively unfavorable prognostically, may be found here in very deceptive imitations. Thus the affected, silly behavior, impulsive actions, temporary verbigeration, senseless word salad, grimacing, stereotypy, attitudinizing, etc., which these patients exhibit, may easily be mistaken for the typical catatonic picture of dementia præcox. According to Raecke's view the hysterical stupor is closely related to the Ganser twilight syndrome. Stuporous conditions may introduce the latter, and, vice versa, Ganser complexes may creep into the stupor. Raecke's stupor, like Ganser's twilight syndrome, frequently develops in criminals immediately after arrest or as a result of great physical or psychic exertion. Sometimes the stupor is preceded by convulsions, at other times by a prodromal stage of general nervousness. In still other cases, unpleasant delusions and elementary hallucinations precede the stupor, which may follow immediately after this prodromal state or may be again preceded by a short attack of mania with clouded consciousness. In contrast to the genuine catatonia, Raecke's stupor as well as Ganser's twilight state, are characterized by a high grade of impressionability to things in the environment, which may at any time suddenly cause a complete transition from an apparently deep stupor to normal manner and behavior. Headaches, vertigo, and various hysterical stigmata are common to both the hysterical stupor and the Ganser twilight state. At times recovery takes place suddenly, but as a rule it is gradual and remittent in character. The duration of the disorder differs. It may last for hours or months, and there generally remains a more or less pronounced amnesia for the entire period of stupor.