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RECURRENT FEAR STATES―PSYCHOLEPSY
There are cases in which the nature of the psychopathic states stands out more clearly and distinctly than in others. They occur periodically, appearing like epileptic states, in a sort of an explosive form, so that some authorities have mistaken them for epilepsy, and termed them psychic epilepsy. My researches have shown them to be recurrent explosions of subconscious states, which I termed psycholepsy. They really do not differ from general psychopathic states, but they may be regarded as classic pseudo-epileptic, or psycholeptic states; they are classic fear-states―states of panic.
M. L. is nineteen years of age, of a rather limited intelligence. He works as a shopboy amidst surroundings of poverty, and leads a hard life, full of privations. He is undersized and underfed, and looks as if he has never had enough to cat. Born in New York, of parents belonging to the lowest social stratum, he was treated with severity and even brutality. The patient has never been to any elementary school and can neither read nor write. His mathematical knowledge did not extend beyond hundreds; he can hardly accomplish a simple addition and subtraction, and has no idea of the multiplication table. The names of the President and a few Tammany politicians constitute all his knowledge of the history of the United States.
Family history is not known; his parents died when the patient was very young, and he was left without kith and kin, so that no data could be obtained.
Physical examination is negative. Field of vision is normal. There are no sensory disturbances. The process of perception is normal, and so also is recognition. Memory for past and present events is good. His power of reasoning is quite limited, and the whole of his mental life is undeveloped, embryonic. His sleep is sound; dreams little. Digestion is excellent; he can digest anything in the way of eatables. He is of an easy-going, gay disposition, a New York "street-Arab."
The patient complains of "shaking spells." The attack sets in with tremor of all the extremities, and then spreads to the whole body. The tremor becomes general, and the patient is seized by a convulsion of shivering, trembling, and chattering of teeth. Sometimes he falls down, shivering, trembling, and shaking all over, in an intense state of fear, a state of panic. The seizure seems to be epileptiform, only it lasts sometimes for more than three hours. The attack may come any time during the day, but is more frequent at night.
During the attack the patient does not lose consciousness; he knows everything that is taking place around him, can feel everything pretty well; his teeth chatter violently, he trembles and shivers all over, and is unable to do anything.
The fear instinct has complete possession of him. He is in agony of terror. There is also a feeling of chilliness, as if he is possessed by an attack of "fear ague." The seizure does not start with any numbness of the extremities, nor is there any anaesthesia or paraesthesia during the whole course of the attack. With the exception of the shivers and chills the patient claims he feels "all right."
The patient was put into a condition close to the hypnotic state. There was some catalepsy of a transient character, but no suggestibility of the hypnotic type. In this state it came to light that the patient "many years ago" was forced to sleep in a dark, damp cellar where it was bitter cold. The few nights passed in that dark, cold cellar he had to leave his bed, and shaking, trembling, and shivering with cold and fear he had to go about his work in expectation of a severe punishment in case of non-performance of his duties.
While in the intermediary, subwaking, hypnoidal state, the patient was told to think of that dark, damp, cold cellar. Suddenly the attack set in,―the patient began to shake, shiver, and tremble all over, his teeth chattering as if suffering from intense fear. The attack was thus reproduced in the hypnoidal state. "This is the way I have been," he said. During this attack no numbness, no sensory disturbance, was present. The patient was quieted, and after a little while the attack of shivering and fear disappeared.
The room in which the patient was put into the subconscious state was quite dark, and accidentally the remark was dropped that the room was too dark to see anything; immediately the attack reappeared in all its violence. It was found later that it was sufficient to mention the words, "dark, damp, and cold" to bring on an attack even in the fully waking state. We could thus reproduce the attacks at will,―those magic words had the power to release the pent-up subconscious forces and throw the patient into convulsions of shakings and shiverings, with chattering of the teeth and intense fear.
Thus the apparent epileptiform seizures, the insistent psychomotor states of seemingly unaccountable origin, were traced to subconscious fear obsessions.
The following case is of similar nature, The study clearly shows the subconscious nature of such psycholeptic attacks:1
Mr. M., aged twenty-one years, was born in Russia, and came to this country four years previously. His family history, as far as can be ascertained, is good. There is no nervous trouble of any sort in the immediate or remote members of his family.
The patient himself has always enjoyed good health. He is a young man of good habits.
He was referred to me for epileptiform attacks and anæsthesia of the right half of his body. The attack is preceded by an aura consisting of headache and a general feeling of malaise. The aura lasts a few days and terminates in the attack which sets in about midnight, when the patient is fully awake. The attack consists of a series of spasms, rhythmic in character, and lasting about one or two minutes. After an interval of not more than thirty seconds the spasms set in again.
This condition continues uninterruptedly for a period of five or six days (a sort of status epilepticus), persisting during the time the patient is awake, and ceasing only during the short intervals, or rather moments, of sleep. Throughout the whole period of the attacks the patient is troubled with insomnia. He sleeps restlessly for only ten or fifteen minutes at a time. On one occasion he was observed to be in a state of delirium as found in post-epileptic insanity and the so-called Dämmerzustände of epilepsy. This delirium was observed but once in the course of five years.
The regular attack is not accompanied by any delirious states or Dämmerzustände. On the contrary, during the whole course of the attack the patient's mind remains perfectly clear.
During the period of the attack the whole right side becomes anaesthetic to all forms of sensations, kinaesthesis included, so that he is not even aware of the spasms unless he actually observes the affected limbs.
The affected limbs, previously normal, also become paretic. After the attack has subsided, the paresis and anaesthesia persist (as sometimes happens in true idiopathic epilepsy) for a few days, after which the patient's condition remains normal until the next attack. After his last attack, however, the anaesthesia and paresis continued for about three weeks.
He has had every year one attack which, curiously, sets in about the same time, namely, about the month of January or February. The attacks have of late increased in frequency, so that the patient has had four, at intervals of about three or four months. On different occasions he was in the Boston City Hospital for the attacks.
There was a profound right hemianaesthesia including the right half of the tongue, with a marked hypoaesthesia of the right side of the pharynx. All the senses of the right side were involved. The field of vision of the right eye was much limited. The ticking of a watch could not be heard more than three inches away from the right ear. Taste and smell were likewise involved on the right side. The muscular and kinaesthetic sensations on the right side were much impaired.
The patient's mental condition was good. He states that he has few dreams and these are insignificant, concerned as they are with the ordinary matters of daily life. Occasionally he dreams that he is falling, but there is no definite content to the dream.
These findings were indicative of functional rather than organic disease. The previous history of the case was significant. The first attack came on after peculiar circumstances, when the patient was sixteen years of age and living in Russia. After returning from a ball one night, he was sent back to look for a ring which the lady, whom he escorted, had lost on the way. It was after midnight, and his way lay on a lonely road which led by a cemetery. When near the cemetery he was suddenly overcome by a great fright, thinking that somebody was running after him. He fell, struck his right side, and lost consciousness. The patient did not remember this last event. It was told by him when in a hypnotic state.
The patient was a Polish Jew, densely ignorant, terrorized by superstitious fears of evil powers working in the dead of night.
By the time he was brought home he regained consciousness, but there existed a spasmodic shaking of the right side, involving the arm, leg, and head. The spasm persisted for one week. During this time he could not voluntarily move his right arm or leg, and the right half of his body felt numb. There was also apparently a loss of muscular sense, for he stated that he was unaware of the shaking of his arm or leg, unless he looked and saw the movements. In other words, there was right hemiplegia, anaesthesia, and spasms.
For one week after the cessation of the spasms his right arm and leg remained weak, but he was soon able to resume his work, and he felt as well as ever. Since then every year, as already stated, about the same month the patient has an attack similar in every respect to the original attack, with the only exception that there is no loss of consciousness. Otherwise the subsequent yearly attacks are photographic pictures, close repetitions, recurrences of the original attack.
A series of experiments accordingly was undertaken. First, as to the anaesthesia. If the anaesthesia were functional, sensory impressions ought to be felt, even though the patient was unconscious of them, and we ought to be able to get sensory reactions,
Experiments made to determine the nature of the anaesthesia produced interesting results. These experiments show that the anaesthesia is not a true one, but that impressions from the anaesthetic parts which seem not to be felt are really perceived subconsciously.
Different tests showed that the subconscious reactions to impressions from the anaesthetic hand were more delicately plastic and responsive than the conscious reactions to impressions from the normal hand. We have the so-called "psychopathic paradox" that functional aesthesia is a subconscious hyperaesthesia.
It is evident then that there could be no inhibition of the sensory centres, or suppression of their activity, or whatever else it may be called. In spite of the apparent, profound anaesthesia, the pin pricks were felt and perceived. Stimulations gave rise to perception, cognition, to a sort of pseudo-hallucinations that showed the pin pricks were counted and localized in the hand. The results of these tests demonstrate that in psychopathic patients all sensory impressions received from anaesthetic parts, while they do not reach the personal consciousness are perceived subconsciously.
Inasmuch as the sensations are perceived, the failure of the subject to be conscious of them must be due to a failure in association. The perception of the sensation is dissociated from the personal consciousness. More than this, these dissociated sensations are capable of a certain amount of independent functioning; hence the pseudo-hallucinations, and hence the failure of psychopathic patients to be incommoded by their anaesthesia. This condition of dissociation underlies psychopathic states.
For the purpose of studying the attacks, the patient was hypnotized. He went into a deep somnambulic condition, in which, however, the anaesthesia still persisted. This showed that the dissociation of the sensory impressions was unchanged.
In hypnosis he related again the history of the onset of the trouble. His memory became broader, and he was able to give the additional information, to which he could not do in his waking state, that at the time he was badly frightened, he fell on his right side. Moreover, he recalled what he did not remember when awake, that throughout the period of his attacks when he fell asleep, he had vivid dreams of an intense hallucinatory character, all relating to terror and fall.
In these dreams he lived over and over again the experience which was the beginning of his trouble. He again finds himself in his little native town, on a lonely road; he thinks some one is running after him; he becomes frightened, calls for help, falls, and then wakes up with a start, and the whole dream is forgotten. After he wakes he knows nothing of all this; there is no more fear or any emotional disturbance; he is then simply distressed by the spasms.
While testing the anaesthesia during hypnosis, an attack developed, his right arm and leg began to shake, first mildly and then with increasing intensity and frequency. His head also spasmodically turned to the right side. The movements soon became rhythmic. Arm and leg were abducted and adducted in a slow rhythmic way at the rate of about thirty-six times per minute. With the same rate and rhythm, the head turned to the right side, with chin pointing upward. The right side of the face was distorted by spasm, as if in great pain. The left side of the face was unaffected. Pressure over his right side (where he struck when he fell) elicited evidences of great pain. Respiration became deep and labored, and was synchronous with each spasm. The whole symptom-complex simulated Jacksonian epilepsy.
Consciousness persisted unimpaired, but showed a curious and unexpected alteration. When asked what was the matter, he replied in his native dialect, "I do not understand what you say." It was found that he had lost all understanding of English, so that it was necessary to speak to him in his native dialect. His answers to our questions made it apparent that during the attack, as in his dreams, he was living through the experience which had originally excited his trouble.
The attack was hypnoidic, a fear attack, hallucinatory in character. He said that he was sixteen years old, that he was in Rovno (Russia), that he had just fallen, because he was frightened, that he was lying on the roadside near the cemetery, which in the popular superstitious fear is inhabited by ghosts. At that hour of the night the dead arise from their graves and attack the living who happen to be near.
The hypnoidic state developed further, the patient living through, as in a dream, the whole experience that had taken place at that period. He was in a carriage, though he did not know who put him there. Then in a few moments he was again home, in his house, with his parents attending on him as in the onset of his first epileptiform seizures
The attack terminated at this point, and thereupon he became perfectly passive, and when spoken to answered again in English. Now he was again twenty-one years old, was conscious of where he was, and was in absolute ignorance of what had just taken place.
It was found that an attack could regularly and artificially be induced, if the patient in hypnosis was taken back by suggestion to the period when the accident happened.
The experiment was now tried of taking him back to a period antedating the first attack. He was told that he was fifteen years old, that is, a year before the accident occurred. He could no longer speak or understand English, he was again in Rovno, engaged as a salesman in a little store, had never been in America, and did not know who we were. Testing sensation, it was found that it had spontaneously returned to the hand. There was not a trace of the anaesthesia left. The hands which did not feel deep pin pricks before now reacted to the slightest stimulation. Spontaneous synthesis of the dissociated sensory impressions had occurred. Just as formerly before the accident, sensation was in normal association with the rest of his mental processes, so now this association was re-established with the memories of that period to which the patient was artificially reduced.
The patient was now (while still believing himself to be fifteen years old) taken a year forward to the day on which the accident occurred. He says he is going to the ball tonight. He is now at the ball; he returned home; he is sent back to look for a ring. Like a magic formula, it calls forth an attack in which again he lives through the accident,―the terror and the spasms.
It was thus possible to reproduce an attack at any time with clock-like precision by taking him back to the period of the accident, and reproducing all its details in a hypnoidic state. Each time the fear and the physical manifestations of the attack (spasms, paresis, and anaesthesia) developed. These induced attacks were identical with the spontaneous attacks, one of which we had occasion to observe later.
At periodic intervals, as under the stress of fear, the dormant activity is awakened and, though still unknown to the patient, gives rise to the same sensori-motor disturbances which characterized the original experience. These subconscious dissociated states are so much more intense in their manifestations by the very fact of their dissociation from the inhibitory influences of the normal mental life.
The psychognosis of such cases reveals on the one hand a dissociation of mental processes, and on the other hand an independent and automatic activity of subconscious psychic states, under the disaggregating, paralyzing influence of the fear instinct.
A patient under my treatment for four months during the year of 1922 presents interesting traits. I regard the case as classic as far as the fundamental factors of neurosis are concerned.
Patient, male, age 32, married, has two children. He lives in an atmosphere of fear and apprehension about himself. He comes from a large, but healthy family. The patient is of a rather cowardly disposition especially in regard to his health. He worked hard in a store during the day, and led a life of dissipation at night. One day, after a night of unusual dissipation, or orgy, when on his way to his work, he felt weak, he was dizzy, he became frightened about himself; he thought he had an attack of apoplexy, and that he was going to die. His heart was affected, it began to beat violently, and he trembled and shivered in an "ague" of intense fear. The palpitation of the heart was so great, the trembling was so violent, and the terror was so overwhelming that he collapsed in a heap. He was taken to his father's store in a state of "fainting spell," A physician was called in who treated the patient for an attack of acute indigestion.
For a short time he felt better, but the attacks of terror, trembling, shivering, weakness, pallor, fainting, palpitation of the heart and general collapse kept on recurring. He then began to suffer from insomnia, from fatigue, and is specially obsessed by fear fatigue. He is in terror over the fact that his energy is exhausted; physical, mental, nervous, sexual impotence, This was largely developed by physicians who treated him for epilepsy, putting him on a bromide treatment; others treated and diagnosed the case as cardiac affection, kidney trouble, dementia praecox, and one physician operated on the poor fellow for tonsillitis. The patient was terrorized. He was on a diet for toxaemia, he was starved. He took all sorts of medicine for his insomnia.
The patient became a chronic invalid for ten years. He was in terror, scared with the horrors of sleepless nights. He has been to neurologists, to psycho-analysts, and he tried Christian Science, New Thought, Naturopathy, and Osteopathy, but of no avail, The condition persisted. The attacks came on from time to time like thunder storms. There were trembling, shivering, chattering of teeth, palpitation of the heart, weakness, fainting, and overwhelming, uncontrollable terror.
The first time I tried to put the patient into a hypnoidal state was nine at night, I put out the electric light, lighted a candle, and proceeded to put him into a hypnoidal condition, The patient began to shiver, to tremble, to breathe fast and heavily, the pulse rose to over 125, while the heart began to thump violently, as if it were going to jump out. He was like one paralyzed, the muscles of the chest labored hard, and under my pressure the muscle fibers hardened, crackled, became rigid, and he could not reply when spoken to. It took me some time to quieten him. He was clearly in a state of great panic. I opened his eyelids and found the eye ball turned up. The whole body '''as easily put in a state of catalepsy. Clearly the patient was not in a hypnoidal state, he was in a state of hypnosis. Night after night he fell into states of hypnosis with all the symptoms of intense fear attacks, When the fear attacks subsided the depths of the hypnotic state proportionately diminished,
In my various clinical and laboratory experimental work, covering a period of a quarter of a century, I have gradually come to the conclusion that fear and hypnosis are interrelated. In fact I am disposed to think that the hypnotic state is an ancient state, a state of fear cataplexy, or rather trance obedience. While the hypnoidal state is a primitive sleep state, the hypnotic condition is a primitive, fear condition, still present in lowly formed organisms.
After some time the general fear instinct becomes alleviated. The patient goes by habit into a trance hypnotic state under the influence of the hypnotizer in whom he gains more confidence. The patient gets into a state of trance obedience to the hypnotizer of whom he is in awe, and who can control the patient's fear instinct.
Man obeys the commands, "the suggestions" of the hypnotizer, of the master whom he subconsciously fears, and who inspires him with awe, with "confidence-fear." The crowd, the community, "public opinion," the mob, the leader, the priest, the magician, the medicine man, are just such forces, such authorities to procure the slavish obedience of the subconscious described as hypnosis. Soldiers and slaves fall most easily into such states.
Man has been trained in fear for milleniums, in fear of society, custom, fashion, belief, and the authority of crowd and mob. He fears to stand alone, he must go with the crowd.
Man is a social being, a hypnotized, somnambulic creature. He walks and acts like a hypnotized slave. Man is a social somnambulist who believes, dreams, and acts at the order of the mob or of its leader. Man belongs to those somnambulists who become artificial, suggested, automatic personalities with their eyes fully open, seeing and observing nothing but what is suggested to them.
The hypnoidic states, observed and described by me in the classical Hanna case, belong to the same category. The hypnoidic states are essentially fear cataleptic states of a vivid character, closely related to hypnotic conditions of primitive life.2
Dr. Morton Prince and Dr. H. Linenthal cooperated with me in the study of the
case published in full in the "Boston Medical and Surgical Journal."