Gentlemen!

The question—if and when a psychosis that has not reverted to full health is to be regarded as having run its course—is, from everything we currently know, one of the most difficult we can pose; and yet it is at once of both theoretical and practical significance. From a theoretical point of view, its importance is clear from the idea that in autopsies of deceased cases we can see only remnants [Ed] of the disease process in the organ of association [1], but no longer the changes themselves, in the organ. In practical terms, cases where active illness is fully extinguished implicitly intermingle their healed deficits with ones that remain in other areas of pathology. Nothing would stand in the way of a patient being discharged from a mental hospital as soon as the change in content of consciousness, taken by itself, becomes harmless, as is often the case for an alleged inventor and founder of new world views. Evidence by which we can answer this question must of course be found exclusively in the area of symptomatology. Our task then is to examine psychotic symptoms we have met so far, with a view to determining whether, and to what extent, they are expressions of a more active disease process.

The simplest example on offer here is that of a delusional idea of a psychiatric patient lacking insight about his illness, who at the time of that illness had been illegally detained and robbed of his freedom. We can assume that such a patient, on resuming a regular job and returning to a normal way of life, would find so many other normal interests that, only if his main interest remained focused on the alleged injustice, would he reveal any particularly unfortunate traits. But let us assume instead that a lawyer, full of legal concepts, suffered the same fate; then his main interest would focus on the injustice he had suffered; and accretion of new delusional explanations would probably become obvious. He might file a complaint claiming compensation. Since ‘what befalls one befalls another’ [W]—there would be no more closely linked notion than that others too might have suffered the same injustice. If his complaints are then rejected, he might come to believe that not only he himself but also his fellow sufferers are deemed guilty; and so he continues to pursue his rights. Constant rejection shakes his faith in Justice; he comes to suspect that judges were bribed, possibly by the same faction that had seen fit to put him away in the mental hospital; or that the law was bent, to cover up the institution’s alleged crimes. Even his earlier personal experience becomes generalized. He now considers every lawsuit from the same point of view, and therefore constantly arrives at new false judgments. Let us make the quite plausible assumption that his wife had arranged his admission to hospital. Even in the institution, he has harboured the suspicion that she has taken up with another man; yet he has fought—and temporarily overcome—this belief. Now however, when outside the institution, the suspicion re-emerges: He begins to observe all of his wife’s comings and goings from this point of view; he pays attention to things he had never noticed before; he highlights remarks of an incriminating nature, and so on. If, following from normal expression of Affects, abnormal jealousy were to arise, delusional jealousy with all its conflicts may end up in the patient’s being readmitted. In all these trials and tribulations the patient now assesses his relationship to other people and to legal institutions incorrectly, according to his biased viewpoint, focusing on whether they support him or his opponents. Thus, we see a whole chain of false judgments being formed; expanding delusions, with each subsequent link as the logical consequence of the preceding one; and, for malcontents, each station along the entire pathway as a possible starting point for their insults and violence. In fact, such non-recovered mental patients are unpredictable in their actions.