Gentlemen!

Before we go any further, it would be advantageous for us to consider in greater detail the patient who is the most authentic example of all acute mental illnesses to whom we have access at present, our instructive case, the engineer K. The psychosis that Mr K. has experienced will not be looked at in any greater detail later, because it represents a very complex and as-yet little known form of illness. For this very reason the case is useful for our present purpose, because the patient not only has personal experience of most of the elementary symptoms that can be derived from our schema for problems of identification, but can also convey with eloquence the effects that they have produced in him. The best general term we have for this effect is disorientation [W]. In disorientation we come to see the real essence of any psychosis. Disorientation disorders included in our schema represent only the route [Ed] by which nature brings about such disorientation; but every psychiatric patient is in some way disoriented. If he is not, then he is not mentally ill in a strict sense. The actual damage that the still-largely-unknown disease process wreaks on mentally ill people is through such disorientation. All abnormal alterations in content of consciousness that occur temporarily or permanently in mental patients are included under this concept of disorientation. From my earlier explanations about our schema, namely the relationship between activity of consciousness and its actual content, these regular consequences of disorientation will appear just as natural aberrant modifications of the activity of consciousness. We are struck by the importance of this aspect all the more, as I already stressed, by the fact that the content of consciousness—and alterations to it—provides us with the most tangible, most obvious, and most easily assessed symptoms. Therefore we will derive our classification of acute psychoses from the material changes brought about by the illness, in exactly the same way as we did for chronic psychoses; and we will find that we obtain a basis for a natural system of classification, with room enough to accommodate all the facts. Corresponding to our classification of consciousness into the three areas—of corporeality, the outside world, and personhood—we will meet the clinical requirement of differentiating corresponding types of disorientation; and here we use the terms ‘somatopsychically’ [Ed], ‘allopsychically’ [Ed], and ‘autopsychically’ [Ed]. In addition, we will distinguish the domain of motility disturbances, which falls partly under the term ‘somatopsychic’ [Ed] and partly under ‘autopsychic’ [Ed], as a special type of disorientation. When disorientation irrupts acutely, as in acute psychoses, it is inherently connected with a vivid Affective response. For this Affective state, the German language offers us the pithy expression Ratlosigkeit [W], a term often used by mentally ill persons themselves. According to this, in what follows, we will also use precise expressions for various colorations of this Affect, with the words somatopsychic, allopsychic, autopsychic, and motor disarray [Ed].

Thus Mr K. spoke spontaneously of the disarray in which he had, for a long time, found himself: ‘He had always wondered; he had not come out of the wonderment’. The sensory delusions to which he had been subjected, in particular, gave rise to this. Since he always remained, by and large, oriented about his whereabouts, and the people in his immediate surroundings, and had even preserved a degree of orientation towards the combined hallucinations, by conceiving them as dream images, we see from this example that the importance of the sensory delusions consists, as we suggested earlier (p. 69), of an image of the outside world exhibiting abnormal accretions, not corresponding to reality; but that reality is, in addition, recognized as such, and so allopsychic orientation can still, to a degree, be maintained. In another sense we must still regard this aberrant growth as disorientating. However orientation to the data actually presented from the outside world is not abolished by the hallucinations. I emphasize this because we will meet the same experience over and over again in acute mental illnesses: Patients cannot be deprived of their orientation by sensory deceptions alone, not even those combining different senses, unless there is a simultaneous state of significant drowsiness. On the other hand, a high degree of allopsychic disarray [Ed] can result. I recently had the opportunity to observe one of the most instructive examples of this principle on the ward. This was a 26-year-old serving maid W., suffering from epilepsy which had developed years previously; who, 1½ years ago in the eighth month of pregnancy, and following frequent epileptic seizures, underwent a brief period of psychosis lasting only 6 days, after which she has become imbecilic, and has since survived repeated shorter and longer bouts of severe, post-epileptic psychoses. Recently she again had four epileptic seizures in 1 day, fell ill with febrile angina the following day, but slept in the evening and the greater part of the night. Towards morning she woke up suddenly, in a state I was able to observe during a ward round 6 h later. She presented with a most Affect-laden picture of despair: fire, hell, and murder threatened her; she should be taken by the devil, torn to pieces, tortured, killed, broken on the wheel, burned, and thrown into water. The world would be destroyed by fire, the city burned, and the Kaiser would come. She heard all this through voices coming from all sides, which she sought to escape by furious attention-seeking, and the most desperate attempts at suicide and self-harm. A whole team of warders was needed to protect her from harm. At the same time she saw heads, shapes, flags, and soldiers at the windows. Despite this, she remained completely oriented, accessible to support and comfort by medical staff, recognized all of the people around her, and greedily took medication handed to her. At the same time she had extreme anxiety in her chest in relation to phonemes. Four grams of amyl hydrate had an immediate calming effect; and she herself said that the terrible speech had subsided, as had the nagging feeling of fear. The attack was thus initially controlled without putting her to sleep. However, similar bouts of lower intensity were repeated over the next 10 days, and only then did normal interictal behaviour occur. With this patient we found that bromide preparations, even in high dose, always failed to reduce her psychotic symptoms.