Psychopathies are not mental illness in the proper sense. They are cases of general disharmony of the personality with the foregrounding of its individual sides, with their hypertrophy far beyond what can be considered individual fluctuations.
The egocentrism of psychopathic personalities prevents them from correctly assessing their behavior. Naturally, this leads to constant conflicts with comrades, with everyone around them, including their loved ones; they all suffer from their injustice, from all their behavior, from their inability to merge with the collective both at work and in the dormitory. By making others suffer, psychopaths, in the end, suffer themselves from their own personality peculiarities.
Hence, it is understandable that such persons, under the influence of their affectivity and instability, often deviate from generally accepted rules of behavior and can commit serious offenses. It is no coincidence that the concepts of "psychopathy" and "psychopathic state" were first put forward in 1884 by I.M. Balinsky in a forensic examination given by him together with Dr. A.B. Chechott.
Later, V. X. Kandinsky developed I.M. Balinsky's views on psychopathies.
The diversity of clinical manifestations, the multiplicity of separate forms, which at first sight seem to have nothing in common, is the main reason why these pictures have not found a correct assessment up to the present time. Quite wrongly, at the time when the role of heredity was overestimated, they were equated with unexpressed forms of schizophrenia, manic-depressive psychosis and epilepsy. The notion that their nature should be based on the image and likeness of the above psychoses, which was erroneous, was used to single out schizoid, cycloid and epileptoid psychopaths. It was also quite erroneous to speak in these cases of transitional forms to this or that psychosis, of its initial manifestations. This mistake was connected with an uncritical attitude to the Kretschmer doctrine of somatic and corresponding mental constitutions, which were seen as fate in the sense of being doomed to illness. The viciousness of this doctrine and its idealistic essence have been fully exposed by Soviet researchers. They reject the fatality of heredity and constitution.
Even in pre-revolutionary times domestic psychiatrists approached the study of psychopaths as pathological characters. S.A. Sukhanov described an anxious-conscientious character, which corresponds to a psychasthenic disposition. P.B. Gannushkin described the hysterical character; later he gave a good description of the clinic of psychopaths in his monograph. His data on dynamics of psychopathies and on the importance of the external, especially social environment for these dynamics is valuable. I.P. Pavlov has no reference to psychopaths. His very important data on extreme variants of normal types makes it possible to come to the conclusion that psychopathies cannot be considered such extreme variants of the norm, since these extreme variants are still the norm, while psychopathy is pathology.
Everyday observations show that the patterns attributed to psychopaths do not appear ready-made already in childhood, but develop over the course of life, undergoing significant shifts under the influence of environmental changes. Therefore, in covering the problem of psychopathies, it is necessary to proceed from an analysis of the development of what is most essential which characterizes them clinically. Their basic feature is that while their cognitive abilities are preserved, they have considerable disorders of the emotions and also of behavior. In cases of disharmonious development of the personality, the unity of action and orientation towards a certain goal is disrupted. Behavior is dominated by actions dictated by random motives, affective impulses, these or other instincts, urges that find no counteraction due to weakness of cortical regulation. In psychopathic individuals, it is possible to assume disturbances in the interaction of cortical-subcortical processes.
Psychopathies can be defined as pathological development of personality formed under the influence of unfavorable external moments on the basis of its natural features. Intrauterine lesions or illnesses of the first years of life can play a role here.
A great role played by traumatic experiences in childhood, improper education and other adverse environmental influences. This is a general disharmony of the personality with inadequate reactions to stimulus from the environment. But abnormal traits under favorable conditions can be suppressed due to the development of healthier sides.
It is necessary to distinguish from psychopathies as developmental abnormalities psychopath-like conditions which sometimes develop as a result of trauma or infections, especially at childhood age. Some cases of epidemic encephalitis as well as those developing in connection with traumatic brain injury have such similarities with psychopathies. Such psychopath-like conditions are of great importance for understanding the essence of psychopathies. The clinical similarity between the two, undoubtedly, can be explained by the fact that there is something in common in the disharmonious development of personality and in the characteristic features of both of these groups. Psychopathic states are processes in stabilization or remission, sometimes only temporarily. Because of this, neurological examination of them always reveals some or other organic signs which do not occur in psychopaths.
Clinical forms of psychopathies
Excitable, explosive personalities are distinguished as a special form. What is characteristic of them, in addition to increased excitability proper, is that their reactions to external stimuli prove to be disproportionate in their intensity and arise under the influence of the most insignificant causes. The behavior of such a psychopathic personality is determined mainly by heightened affectivity; it is often unreasonable and does not correspond to the wishes of the psychopath himself or to his social attitudes in a tranquil state. Such phenomena as fits of rage and furious rage, aggression toward others, and suicide attempts are common. Intoxication greatly increases their excitability and makes it especially easy to commit various acts of violence. At the end of an angry outburst, in the intervals between attacks, psychopaths of this kind are correct, placid and sociable, aware of the incorrectness of their behavior and not averse to making amends to the victims of their morbid excitability.
There are reasons to allocate emotionally labile psychopathies with frequent mood swings. Known mood swings are peculiar to all psychopaths, but the cases in question hold a special position. Such individuals can have states of deep melancholy or states of heightened well-being which do not correspond to external conditions. P.B. Gannushkin allocated psychopaths-hypertimic, i.e. persons with morbidly heightened state of well-being, and dysthymic, i.e. inclined to melancholy.
Changes in emotionality not only in the sense of lability, but also in the sense of great excitability and their dependence on external moments characterize psychopathic personalities, which have been called hysterical. Most essential to hysterical psychopaths is emotionality and suggestibility; they are selfish and self-centered. The hysterical personality is characterized by a striving for a beautiful pose, a desire to appear better, more interesting, more significant than in reality. Characterized by a desire to always play a role, to present themselves to others as a particularly interesting, talented person, which do not understand and can not appreciate the others, the desire to show themselves as a deeply sensitive and subtle nature, which in attempts to implement their high aspirations stumbles on the rudeness of others, and very often finds himself in the position of the victim. The means for attracting attention are various fantastic stories, which the hysterical person can very easily invent thanks to his lively imagination, and it often comes to deception and simulation of various painful phenomena. The hysterical psychopath turns out to be blind and deaf to everything that does not correspond to his mental attitude. As a consequence of this, hysterics' ideas of the environment and in particular accounts of various events in which they are more or less interested are usually full of contradictions of reality. It is necessary to keep in mind that in this case a considerable role is always played by a considerable admixture of conscious fictions. With the latter it is necessary to take into account that they are usually constructed with the lively imagination peculiar to such psychopaths and are quite often accompanied by talented staging.
Psychasthenic psychopathy should also be referred to abnormal development of personality. We have described the characteristic features of this psychasthenic personality in the chapter on neurosis. This is a particular type of personality. Most characteristic of it is anxiety and mistrustfulness, indecisiveness. The most essential consists in fruitless speculation, endless reasoning which does not lead to any concrete actions, in constant doubts and hesitations. On a background of such a condition, various compulsions easily arise under the influence of mental traumatization.
A special group consists of asthenic psychopaths - individuals who are characterized by heightened sensitivity, vulnerability, extreme timidity and shyness. They fatigue easily and become exhausted.
In some cases, the main features of the psychopathic personality are reticence and suspiciousness, as well as irritability and antagonism, along with more or less pronounced oddities in behavior. Such people are commonly referred to as oddballs, weirdos. As a result of their lack of coexistence, they are usually lonely and poorly adapted to their environment. Accordingly to the basic properties of psychopaths of this type, we have suggested calling them pathologically withdrawn. By these psychopathic features they differ from withdrawn, but normal people.
According to I.P. Pavlov, reticence in itself does not contain anything special, but is an indicator of extreme difficulty of the social environment for such people with a weak nervous system, why there is a natural removal from it. I.P. Pavlov believes that strong people with certain aptitudes, focused on a single task, fascinated by a single idea can also be withdrawn.
Querulous psychopaths can be singled out as a special group. Such psychopaths, being distrustful and suspicious and at the same time somewhat active, may have not only an unfounded belief that they are being harmed, but also a desire to defend themselves, to assert their rights by making official statements to various institutions, complaints to the courts. The groundlessness of these complaints leads, naturally, to their rejection or abandonment. This further convinces psychopaths that they are being treated unfairly. In some cases of psychopathy of this kind, you may get a picture that is difficult to distinguish from paranoia.
Sometimes the most significant thing is the emergence of sudden urges which prove impossible to resist. They differ from compulsive actions by their suddenness, lack of a preceding more or less prolonged stage of struggle with craving. Such, for example, is the impulse urge to aimless wandering (dromomania). It is possible to speak in general about impulsive psychopathies.
A known group of psychopathic individuals is characterized by heightened sexuality. Their sexual attractions often appear unusually early, but this early appearance may not always be an indication of greater sexual activity in the future. Sexual desire as such in psychopaths is usually quite strong. One could even say that the attention in this respect is particularly acute. In this connection such persons usually greatly overestimate the importance of all the points relating to this area, but the aggravation of attention does not always correspond to a sufficiently active sexuality in the proper sense; there is often an undoubted weakness of a purely physiological order, which is a favorable ground for various kinds of deviations in this area. Weakly expressed and insufficiently formed in the sense of direction to its direct purpose - procreation - sexuality can very easily go the way of different deviations. First of all it must be kept in mind that an attraction that is not strong enough for sexual intercourse needs stronger stimuli, and the latter are present in perversions. To a certain extent the phenomenon of sadism and masochism should also be looked at in this way. Sadists, in order to obtain sexual satisfaction, inflict pain, and masochists obtain satisfaction when pain is inflicted on them.
In the pre-revolutionary period sadistic tendencies sometimes found an outlet in the use of corporal punishment with particular cruelty, as was the case with "soldiering" or often in schools. Closely related to this is exhibitionism - the desire to expose one's genitals in the presence of the other sex for sexual gratification. Perversions include masturbation, sometimes carried out by irritation of the genitals, sometimes only through fantasy, evoking sexual images in one's imagination (mental onanism). The weakness of the normal sexual drive can be seen at the basis of homosexuality, in which it is directed to subjects of the same sex (pederasty in men, a similar disorder in women - lesbian love). Sexual anomalies were very common in pre-revolutionary times. They are still found today in capitalist countries, where sexual sophistication is cultivated. In the USSR, these types of psychopathies are exceptionally rare. This example shows the importance of social conditions for the development of psychopaths. There are grounds, therefore, for singling out psychopathies with sexual perversion.
Child psychiatry in the Soviet Union provided much valuable insight into psychopathy. Only in childhood is it possible to trace so completely the formation of pathological character. In contrast to bourgeois theories treating psychopathies only as hereditary conditioned pathological states, Soviet child psychiatry has long been categorical in stating that psychopathies are formed mainly under the influence of external unfavorable factors on the child's unstable psyche.
It is very difficult to make a diagnosis of psychopathy at an early age. A young child, due to insufficient inhibition of the subcortex by the cortex, is normally marked by mild excitability, unbalance, and affective lability. The child's characteristic heightened suggestibility and the associated easy accessibility to influences of his or her surroundings can disrupt the harmonious development of his or her personality. Being in this or that environment, he or she is influenced by it. Under adverse conditions, he or she develops such traits, such features in his or her relationship to others, in behavior which, without being corrected by education, become fixed, hypertrophied and become the germ of psychopathy. Of course, a child's behavior does not copy only what he/she sees in others. It can also demonstrate its own behavior, but in order for this behavior not to have slopes into pathology, it is necessary that it be created in a healthy environment and that it be stimulated by healthy stimuli.
Prevention and treatment of psychopathy
The prevention of psychopathy coincides with neuropsychiatric prevention in general.
While psychopathies were looked upon as rudiments of a disease based on hereditary aggravation, their treatment was hopeless; but when they came to be seen as developmental anomalies, in genesis of which great role played external unfavorable factors, certain prospects were opened before treatment.
Of primary importance is the work orientation of the psychopathic personality, which must be stimulated. The organization of a favorable environment is of great importance. Neurotic reactions and reactive psychosis easily arise in psychopaths under the influence of traumatic experiences; they demand appropriate treatment.
The foundations of neuropsychiatric health are laid very early and further life in many respects depends on what influences childhood. Morbid nervous phenomena in a child, if not eliminated, can grow into a serious disorder. Using the principle of unity of body and environment, we must pay great attention to the conditions in which the child is growing and developing. Various abnormalities in the developing personality are usually easily removed in the conditions of a normal collective. It is necessary to take into account that pathological deviations in the psychopathic personality exist mainly not in intellectual activity, but in emotional-volitional. We should try to instill in the psychopath healthy interests and to involve him or her in work, the nature of which should correspond to age and the skills he or she already has. A great many psychopathic children can attend mass school. Under these conditions, painful influences are rather pushed aside, willpower is strengthened and discipline is instilled. In more severe cases of psychopaths, education and training in special neuropsychiatric institutions is necessary. Combating social neglect is of great importance. Past experience has shown that in conditions of homelessness such patterns of wrong behavior can develop which are difficult to distinguish from psychopaths proper.
When directing teenage psychopaths to work, it is necessary to try to make sure that it corresponds to their abilities and interests. It is necessary to remember that on the basis of the emotional instability which is characteristic of psychopaths, alcoholism can often develop which in this case can take a very grave form and lead to mental degradation.
In worsening mental condition and in more severe cases in general, hospitalization in a psychiatric hospital is indicated; after discharge, psychopaths must be under medical supervision. In severe cases of psychopathy, the question of compulsory treatment in an institution with a work regime may be raised.
The dynamics of psychopaths
Preliminary remarks
Life is a constant development; life phenomena never remain stationary, immovable, unchanging; and in the field of interest, as indicated above, the static study is far from exhausting the whole problem. The dynamics of psychopaths; which should supplement the statics, can be understood broadly and narrowly. It is possible to try to outline the life curve of constitutional psychopaths, i.e. to describe the peculiarities of their biological development and all the ways in which different groups of them at different periods of their life develop their relationship with the environment; on the other hand, it is possible to limit ourselves to the framework of exclusively pathological moments of psychopathic dynamics, i.e. mainly describing short-term and long-term, acute and chronic psychopathological phenomena in them for various reasons and occasions developing. We, proceeding from the data of psychiatric clinic, are compelled to choose the second type of the decision of a task in front of us. However, for complete picture we cannot avoid at least short enumeration of those moments, which are dynamic in life of each person, and psychopath in particular.
The idea that the human personality, even during its normal development, usually undergoes radical changes and is sometimes unrecognizable is not only frequently encountered in the works of psychologists, biologists and doctors, but is also a favorite theme of many poets and artists of the word. A very successful form of this thought was given by Foster. "In the course of a long life," he says, "a man may appear to us successively in the form of several personalities, so different to the extent that if each of the phases of that life could be embodied in different individuals who could be brought together, they would form an extremely diverse group, hold the most opposite views, have deep contempt for one another, and would soon disperse without showing the slightest desire to reunite again. This transformation of personality occurs for the most part not only through an even evolution, but also as a consequence of a series of shifts that interrupt from time to time its quiet and slow development. These shifts, above all, correspond to those periods when there are major changes in the activity of the endocrine glands, the so-called age crises. The most important of these crises are the juvenile, corresponding to the period of puberty, and the opposite to it - the climacteric or pre-marital, the era of the decay of sexual life. The significance of these crises in the dynamics of psychopathies consists in the fact that they are periods of perturbations, when poor or well-established equilibrium is broken and the personality, suddenly thrust into unaccustomed conditions of biological existence, is easily traumatized and at times crashes. The period of puberty (14-18 years old) is the age at which the first distinct appearances of psychopaths as well as genuine psychotic outbursts can most often be observed. One never knows what this age will bring, and parents always fearfully anticipate all sorts of surprises. Adolescents become restless, restless, disobedient, irritable. A natural and healthy protest against the often abusive elders grows into senseless stubbornness and ridiculous opposition to any reasonable advice. Arrogance and self-confidence develop. A shift in motor skills makes the adolescent clumsy and creates in him a sense of growing strength and a sense of acute dissatisfaction with himself at the same time. The presence of newly awakened new urges in the absence of serious content that sets them within certain limits, the passionate search for recognition by others of his own significance and maturity in the absence of an opportunity to achieve it by real means-all this encourages the young man to set himself goals that are clearly unattainable, that make him want to appear more than to be and gives his facial expressions and gestures a character of mannerism and staginess and the whole appearance a touch of pompousness and theatricality. The awakened sexual feeling powerfully demands satisfaction and, especially for young men, induces excesses in Venere or masturbation. The mistakes made by young people, given their general instability and their tendency to unreasonable mood swings, often give rise to short but sharp outbursts of despair, leading to irreparable acts, such as suicide attempts. All these irregularities and roughnesses in psychopaths are usually much more pronounced than in average, so-called "normal" young people. Besides, the picture of pubertal development in them is strongly complicated, on the one hand, by frequent occurrence in this period of real psychotic attacks, and on the other hand, by a number of irregularities in the very timing of the onset and course of this period. In them we often meet both excessively early (pubertas praecox), and on the contrary, delayed puberty, and in both cases it is often disharmonious, incomplete, partial. All stated causes in each separate case an extremely motley interweaving of the most various phenomena, a whimsical crossing of the most various reinforcing or braking each other tendencies and makes the psychology and psychopathology of adolescence one of the most difficult problems.
After 20-25 years of age, the person becomes more balanced and calm. Not very deep psychopathic features from this age begin to level out gradually, youthful unbalance and affectivity disappear, the person becomes better adjusted to life, becomes more tactful, "smart", practical and drier. At the age of 45-55 there is a new endocrine shift and at the same time general sclerotic phenomena begin to develop. As a result, the mental equilibrium of the individual is again endangered.
The symptomatology of this premenopausal crisis is much poorer than that of the preceding pubertal crisis. It is characterized chiefly by some impoverishment of emotional life, narrowing of interests, development of pessimism, avarice and suspiciousness, and in more sharply expressed pathological forms, by pictures of depressive, hypochondriacal, paranoid states. The number of progredient mental illnesses beginning at this age is considerably higher than it is in the middle decades of life. The terms defining the boundaries of this period, as well as the pubertal period, are subject in psychopaths to quite significant deviations from the norm, especially often in the direction of the early onset of phenomena of withering (senium praecox).
The further development of the personality usually leads to development of organic (arteriosclerotic in brain vessels and atrophic in the brain tissue) phenomena; Note that with "normal", well-balanced people, old age is a period of peace of mind and a special rich in experience wisdom which, however, with the tendency of old people to freeze on the stock of ideas acquired in younger years and their inability to perceive new and original things introduced into life by the younger generation, often turns into rather harmful "foolishness". In those psychopathic forms which are characterized by insufficient or unilateral development of efficiency, especially of social feelings, old age often debuts with an ugly protrusion of gross selfishness, mental callousness, pathological avarice, etc.
It would be quite wrong to think that there is one scheme of age development for all people. On the contrary, it is necessary to emphasize with all determination that, without mentioning the individual peculiarities peculiar to the life cycle of each individual, for each of the constitutional groups, some particular type of expression and course of age changes can be outlined for the kind of psychopathy. The complete underdevelopment of this question does not allow us to dwell on it in detail; at any rate, we must never forget that the constitutional features of personality have an effect not only in its static appearance, but also in its dynamic age development.
The above is far from exhausting all the points determining the dynamics of personality. The course of each person's mental development is conditioned not only by internal tendencies inherent in its organization, but also by a variety of exogenous factors. Among these latter, of greatest importance are, on the one hand, various chemical-physical influences - intoxications, injuries, infections (especially often tuberculosis, lues, alcoholism), as well as lesions or individual organs or the whole body, and on the other - influences experienced by the personality from the environmental and social environment. As to the moments of the first order, only in very rare cases it is possible to ignore their role; more often the mental shape of almost every elderly person bears some traces of organic influences conditioned by these moments. But, of course, they recede far into the background before those powerful and transforming influences on the personality, which the social environment in the broad sense of the word has on it. It must not be forgotten that the latter is as necessary for man's spiritual development as air is for his physical existence. The objects for the satisfaction of his desires, the content of the mental acts themselves, the norms of behavior, grief and joy - all this man receives exclusively from it. His conflict experiences, which are often fatal for him, are also determined by his relations with it. For those psychopaths who are characterized by weak will, excessive suggestibility and susceptibility to bad influences (astenics, unstable, hysterics, etc.), this or that influence of environment often turns out to be decisive, determining their entire life path, their entire fate.
Perhaps here it is appropriate to mention one factor of great situational importance, the role of occupation in the life of a psychopath. This is a large question, requiring special study, and here we would like to point out two sides of the matter. First, a psychopath sometimes chooses his profession in accordance with the properties of his psychopathy (a peculiar selection), thus achieving internal balance and harmony; second, the profession cultivates those properties of the psychopathic personality which would otherwise be undetectable. Whether it is possible to speak of "professional psychopaths" (beggars, prostitutes, etc.), we think not. This would contradict all the basic tenets of our work.
Besides the propensity of psychopaths to give excessive aggravation of phenomena in their development, during turning points, during "crises", their psyche also turns out to be extremely unstable in relation to all other factors. These are, on the one hand, the various kinds of periodic fluctuations of life processes that are of little importance in ordinary people (the best known of which are menstruation), and, on the other hand, the just mentioned influences of the external environment: physical and chemical and social. In relation to all these factors, most psychopaths show great vulnerability, great "lability", giving sometimes for the merest reasons a variety of "pathological reactions". This ability of psychopaths to easily lose their mental equilibrium is responsible for the fact that psychopathic ground, as a rule, gives much more vivid and diverse "dynamics" than normal, of course, dynamics pathological in the immediate narrow sense of the word. The following chapters will be devoted to the description of phenomena belonging to this field. We will distinguish, according to pathogenesis, between "spontaneous", "autochthonous" or "idiopathic" attacks or phases that occur from time to time without any visible external cause, on the one hand, and reactions, i.e. psychotic symptom complexes that are a response to various external stimuli, both somatic (somatogenic reactions) and psychiatric (psychogenic reactions), on the other. There is no sharp boundary between phases and reactions, and in relation to a number of pictures, it is very difficult to decide which group to assign them to. Psychogenic reactions are further divided into shocks, reactions proper, and developments.
A common feature of all these pathological conditions is the fact that they differ in their course and outcome from so-called progredient psychoses. A considerable part of them ends with the restoration of a normal pre-psychotic state, at least as far as each individual attack is concerned. It is true that delirium of paranoiacs rarely and usually only partially reverses itself, and after severe long-term reactive states or as a result of frequent change of phases of circular psychosis sometimes there are already persistent phenomena of mental disability, but the basic difference of these peculiar "initial states" from initial states of progredient psychoses is that here we have exclusively the results of excessive overload of brain exhaustion, there is also its destruction by a malignant process; here the brain is damaged; there is a damage to the brain. Finally, whereas in all the cases of interest here it is usually a question of subtle changes which leave the personality generally intact, the process psychoses extend their destructive effect to all aspects of mental life, often changing the whole personality of the patient beyond recognition.
The question of the relationship between the psychotic states described below and the ground on which they arise is decided not only in terms of greater or lesser stability and endurance of the personality, but, much more importantly, also in terms of the correspondence of the reaction pattern to the qualitative features of this or that psychopathy. In general, it is possible to believe that each psychopathy corresponds to a particular way of reacting to external influences that is characteristic of it. Accordingly, both phases and reactions of every kind always receive their specific imprint from the constitutional ground upon which they develop. This provision, however, has only a relative meaning, and experience shows that many of the forms described below, both spontaneous and especially reactive, can occur in psychopaths of different temperaments. It must be borne in mind that a certain trauma, a certain situation may shock and reveal only one corresponding side of the psyche of a constitutional psychopath, thus enabling the development of the same clinical pictures (with differences in detail of course) in psychopaths of different types; on the other hand, the same psychopathic ground - depending on the content of the shocking moment - may produce different types of reaction.
In conclusion, we feel it necessary to point out that our main attention in this section will be devoted, on the one hand, to elucidating the mutual relations of individual psychotic forms, and, on the other, to establishing the connections connecting these forms with these or those predispositions. However confused and however little researched this question may be, we feel that we must devote special attention to it, since it is willy-nilly brought to the forefront by itself for the researcher in this field. Such a construction of our exposition frees us from the necessity of detailed descriptions of the extremely diverse and varying pictures observed in this field.
When it comes to new clinical forms, to new clinical manifestations - which in comparison with the statics of psychopaths must surely be considered phase, shock, reaction, development - the question necessarily arises as to what new form of life this new form brings with it to the psychophysical organization of the psychopath. It is very easy and certainly necessary to answer this question in the affirmative, but it is extremely difficult to put concrete, definite content into this answer. When a schizoid psychopath falls ill with schizophrenia - there is something, if I may say so, grossly, organically, cerebrally new in this process, the same as when an epileptoid psychopath falls ill with epilepsy; but what this newness is, how to understand it, how to evaluate it - no one has yet indicated it. Less subtle, less, perhaps, crude, but still undoubtedly something new is introduced into the psychopath by the phase, the shock, the reaction and, of course, the development. The difference, say, between a cyclothymic ground and a sharply expressed attack of circular psychosis, between an emotionally labile constitution and an attack of reactive stupor as an expression of shock, between this or that constitutional predisposition and a prolonged reaction developing on the basis of this predisposition, is too clear, too great, to speak only of a quantitative difference. The same, of course, applies to development. In the most general terms, this new finds expression:
- In a different, altered form of functioning of the autonomic system, the endocrine apparatus, and the vessels
- in the development of new conditioned reflexes, in the creation of new skills
- in the development of peculiar compensatory mechanisms and, finally.
- in revealing those mechanisms - old, primitive ones - which do not function under normal conditions any more. The following changes can be observed in brain functioning: excessive excitation, resp. inhibition of cortical activity, general or partial; spreading of excitation, resp. inhibition to usually unaffected areas and systems of the brain; finally, loosening or even temporary destruction of connections usually operating in the general system.
In his textbook (1930), in the introductory general remarks to the chapter on reactions (Krankhafte Reaktionen), Bleuler treats the question of psychology and the mechanisms of these reactions in detail. Many of these considerations seem to us worthy of full attention; however, as a whole, Bleuler's whole construction seems to us little systematized, little homogeneous and even motley, and in some of its parts not only abstract and speculative, but altogether unacceptable from a general philosophical point of view. By these words we do not mean to say that the difficult problem of the mechanism of pathological reactions has already been solved by anyone; apart from the most general formulas we have nothing here yet. Here we will mention the attempt of a great psychiatrist such as Reichardt to penetrate also into the meaning of the mechanism of reactions; this can be seen from his view (1930) of the necessity to distinguish between neuropathies and psychopathies. He sees in the basis of the former (visceralnervöse Störungen) disturbances in the vegetative or endocrine system; in the basis of the latter, disturbances in the sphere of instincts, temperament or character (Abnormitаten in der Trib, Temperaments und Сharakterѕrhage). We must make it quite clear here that we do not sympathize with this division and this understanding of things; we cannot understand the difference between neuropathies and psychopathies (one of these terms should be destroyed; it seems to us that this fate should befall the term "neuropathy"). Such a division would mean a return to a slippery and pernicious phase in the history of psychiatry. Are "instinct, temperament, character" separable from the endocrine apparatus or the autonomic system? Is not exogeny, resp. psychogenia, involved in Reichart's neuropathies? In all these divisions we tend to see attempts, - superfluous, unsuccessful, untimely, - to put a concrete content into this or that concept, without being aware either of the scope of the concept or of the meaning of the content; it is a matter of verbal formulas without true knowledge.
Pathological reactions (psychogenic)
Turning to those forms of constitutional mental disorders, the development of which is provoked by certain external causes, certain emotional traumas, we must at the outset say quite definitely that, although we have divided them into different groups for the convenience of description, there are none of the fundamental differences between the latter, which, for example, exist between phases and reactions. Whether we are dealing with an acute and brief disorder of consciousness resulting from an excessively violent sudden shock, or with longer psychotic attacks having at their root some kind of psychic trauma, or finally with the pathological development of the personality of some psychopaths, which takes over almost the entire conscious life, in which this latter changes slowly and gradually under the influence of small everyday external influences and affective influences, we shall find between all these cases the difference, chiefly, only The foregoing, of course, does not at all exclude the necessity of subdividing this chapter into a number of divisions corresponding to the inevitable differences in the clinical picture and in the course of individual groups of cases, in the interests of clarity and systematicity of presentation. But, first of all, we need to dwell, at least briefly, on the question of the mechanisms which bring to life those pathological phenomena which we call psychogenic reactions or reactive states. Here, it is perhaps most important to point out that in a significant number of cases these are the mechanisms that are also active in "normal" mental life. Physiologically, these are, first of all, mechanisms of unconditioned and conditioned reflexes: excitation, inhibition, combination, disruption, etc.; in some cases, excitation extends to areas not usually affected by it, causing and fixing a number of unusual combinations; in others, inhibition becomes excessively deep, sometimes unleashing primitive automatisms suppressed under normal conditions; thirdly, there is a sudden destruction of associations that already seemed firmly established. Psychologically, the notion that there is no unbridgeable boundary between norm and pathology in the field we are studying corresponds to Jaspers' statement that most psychogenic reactions are characterized by one common feature, namely, the feature of their understandability: first, in terms of psychological possibility to explain the phenomenon as a result, as a consequence of the experience that caused it and, second, in terms of the presence in the life forms in which it appears of a certain meaning and purpose.
Practically one of the most important forms of this "understandable" connection of reactions with the influences that caused them is "escape from reality" or "flight into disease," when an unstable personality, striving to free himself from the intolerable gravity of the situation in which he finds himself, either simply shuts this situation out of consciousness, or escapes from it in a more artful way, half-consciously playing out a painful state, or finally employs both of these methods simultaneously.
Another type of "understandable" connections is provided by the case when the subject, consciously or unconsciously, tries to somehow compensate his own insufficiency - an apparent or imaginary insufficiency, or really existing one - tries to somehow compensate his failures in life, to create instead of them a surrogate and in these attempts reveals those traits of his psyche which have been latent before (aggressiveness, propensity to overestimate these or those ideas, propensity to delusional constructions, to theories of the human mind, etc.). In one way or another, the man tries to find himself such a position, at least for a while, which would allow him a way out of the unbearable for him, unacceptable, unbearable situation; he becomes demanding to care, attention, trusteeship (compensatory parasitism). Finally, depression, melancholy after a misfortune is natural, "understandable"; fear and ideas of persecution after a search and arrest are "understandable"; hallucinations in solitary confinement are "understandable," etc., etc. We use the term "understandable" in quotation marks, because any such phenomenon is both understandable and incomprehensible: for if it exists in real life, it is conditioned by something and can be understood; but it is incomprehensible because it exceeds the limits of the usual average types of reactions. The issue of "understandability" of the links is definitely a relative and conditional one; but its clinical significance is still very great, since absence or presence of this "understandability" is of great help in differential diagnosis between psychopathy and a disease process (schizophrenia), and absence of this clinical and psychological attribute usually speaks for schizophrenia and against psychopathy.
In the clinic of reactive states, the disorder of consciousness syndrome has a very important general importance, although it does not fill in all the clinical content of the corresponding cases; this makes us dwell on this symptom before we move on to a description of individual forms. This syndrome almost defies description. The easiest way to characterize it is by a negative sign - the inability to correctly assess one's surroundings. On the quantitative side, it is defined by a greater or lesser - sometimes up to complete extinction - pallor of perceptions. Reactive disorders of consciousness are characterized by a feature often called the figurative term "judgment of consciousness": concentration on a narrow circle of experiences with forgetting, switching off everything else from consciousness. At the same time, it must be remembered that the syndrome described has some positive content: the patient's psyche not only shuts off impressions of the outside world, unwanted memories, etc., but is often filled with a number of affective-colored experiences and fantastic images. In many cases, the analogy of disturbed consciousness to a dream, in which, instead of the switched off reality, the mental world is filled with images, although unreal, incoherent, but nevertheless having the closest relation to the most intimate experiences and feelings of the individual, is involuntarily evoked.
As for the specific manifestations with which the syndrome of reactive disorder of consciousness is found in individual cases, it may vary considerably due to the etiological moment, constitutional factors, and various other conditions, a circumstance which allows us to identify several different forms of it. The simplest are fainting spells, stupor states and attacks of elementary motor agitation ("seizures"), which are the result of mental shocks. A more complex group of cases is formed by the long-standing states that occur most often in imprisonment and unite the phenomena of loss of consciousness with elements of demonstrativeness and deliberateness (Hanser syndrome, purilism, pseudo-demonstrations). These are akin to twilight states, sometimes developing after failures in love, resp. family relationships, after loss of close people, etc. - states whose basic characteristic feature is replacement of reality with dreamlike experiences from the past, as well as pictures of realized desires or fears. At last, the last group is formed by pictures of close to a delirium of fantastic experiences ("delirium-like" fantasies, "waking dreams").
Turning now to the study of individual clinical pictures which are subject to our study, we must first turn to the most acute (catastrophic) forms, which it is most convenient to call conditionally "shock reactions.
There is another way for "comprehensible new formations," a way which, however, seems so unconvincing to us that we dare not speak of it in the text of the work, but only in a footnote. The question is about those cases when a man, in our case a man of a certain psychopathic type, spends much energy, much moral and intellectual strength on one or another idea, on one or another goal of life; in a certain moment he becomes bitterly disappointed in his activity, comes to understanding of futility of his work, which cost him so much and - finds himself in such unstable psychical state, that under the influence of this or that shock he has pathological reactions. This way of forming new "understandable" connections seems to us unacceptable because, if a person is really convinced of his mistakes, he is so subdued by his new attitudes in life that he has nothing to grieve about and nothing to react to the past; otherwise, he should not deceive himself and others: Those enormous expenditures of mental energy, which he has made, have not passed for him, thanks to his inferiority, they have exhausted him, he has become not what he was; in these cases one may speak either of "acquired neurasthenia" or of permanent disability, or, finally, of asthenic development, of course, which is due to the presence in the psyche of this person, resp. psychopath, asthenic sting.
