Gentlemen!

Patient Sch., who you see before you, came only reluctantly to the lecture theatre. He looks around anxiously, comes closer, but hesitantly, and then greets me as an acquaintance. You see him as a 55-year-old, heavily-built man of poor nutritional status, with somewhat cyanotic discoloration of face and hands, and cool extremities, fearful in posture and facial expression. Again and again, he repeats in a rhythmic manner a low moan, and also interrupts his speech every so often, when he shows a great need to express himself. When I interrupt him to give you information, he resents it. He gives correct answers to my questions about his age, family situation, and home town, but you will notice that due to his Affective state, his concentration is impaired; and he introduces pauses, during which he looks around absent-mindedly, so that his answers to simple questions, which would otherwise be quite prompt, sometimes take a long time to reach their conclusion. He also repeatedly suggests that it is difficult for him to concentrate. The impression we gain from his prevailing Affective state is one of bewilderment, anxiety, and disarray. The fact that such Affective states complicate an orderly train of thought has long been known, and has frequently been shown to you. On enquiry we learn that the patient complains of unceasing anxiety. If the seat of the anxiety is in his heart: ‘It wants to crush him’ [W]. He is also breathless, and therefore is sleepless at nights. The patient therefore wished to be examined by me, and in his anxious and overhasty manner, made arrangements to undress. When asked why he is afraid, he tells me of his fear of being beheaded; he had also heard that each day he would receive 50 lashes, counted-out; he would be expected to eat a roll that had lain in a fellow-patient’s spitting glass. On questioning, we hear that other patients lying in the same room with him made these statements. Therefore the patient is well oriented and knows he is in a clinic for the mentally ill. However, he has not judged the current situation quite correctly; and presumably his viewpoint was already rather limited, as we often find among country folk from his region. He knows me; he recognizes the audience as students, and thinks that I have granted them ‘an hour’ [W], but he believes that all men there want to be ministers of religion, like his son, who is currently a theology student and accompanied him to the clinic. On the ward, the patient also claimed that they would cut off his head; he would be taken to the place where corpses were stored. Incidentally, it is not primarily fear from these threats that dominates this patient; rather, we usually hear from him his complaints about the fate of his family. He believes that all his possessions were gone: His son would no longer be able to study. He heard the voice of his young son saying: ‘For three weeks we have had nothing reasonable to eat’ [W]; he had also seen his son standing in front of him, with a pathetic gesture. He believes that his family will all die of hunger; the children are all sickly; his son, the student, was refused life insurance due to heart failure. It was his fault; he had shamed himself by an immoral lifestyle and secret sins of his youth. He had become lazy. He had also harmed himself by chewing a lot of tobacco. The patient tells of an assault, during which he recognized one of his attackers and reported him. He had probably committed perjury at the time, because it had been night, and he could not see clearly. Earlier, when his anxiety was even greater, he also complained that his two youngest children had been poisoned, and his wife had taken her life. At the same time this patient, who has suffered a hernia, eats only meagerly, and says that he gets abdominal pain after a meal.

Apart from the hernia, no organic disease can be found in this patient; and in no way does he look older than his age, but rather younger. He has now been in the clinic for more than a month, and was ill for about 3 months before that. The ‘external cause’ [Ed] of his illness was said to be that the patient, proprietor of a village smithy and associated farm holding, sold his plot of land and the blacksmith’s workshop in order to retire. Although this transaction turned out to be quite advantageous for him, with a smooth transition, the idea gradually came to him that he had ruined his family and would impoverish them. Gradually this idea was joined by anxiety, self-blame in reference to alleged perjury (see above), and the idea that he was a great sinner and was being persecuted by Satan. These autopsychic ideas of anxiety existed on their own in the initial period of illness, and only shortly before his admission were they joined by those of fantastic threats; and at the same time, there was an increase in the patient’s restlessness, which became so noticeable that it was inevitable that he be transferred to an institution. At this time, he seems to have reached the most critical point in his illness and even to have moved beyond it. This is supported by a reduction in his somatopsychic ideas of anxiety. Moreover, the phenomenon had been present, of which there is now no more than a hint; his rhythmic moans, which had been much more pronounced early in his stay, had risen from time to time to monotonous repetition of the same phrase, ‘I, a poor sinner’ [W]. This was occasionally accompanied by rhythmic movements of his arms. Also, anxiety seemed to have reached its peak at about this time. Eating became difficult only at the time when there were these somatopsychic ideas of anxiety; and sleep had to be induced mainly through sleeping pills. His body weight of 78 kg at the time of admission fell to 72 kg, where it is at present; so his food intake has usually been quite sufficient.

As for his prognosis, based on progress so far and other evidence, we are quite confident in viewing it favourably. The course of his illness showed an acute origin followed by increase in symptoms over about a week, in which parakinetic and hyperkinetic symptoms appeared in the form of verbigeration and rhythmic arm movements. This period corresponded with the height of his anxiety and production of somatopsychic ideas of anxiety. Since then independent motor symptoms and likewise his symptoms of hypochondria have ceased, and anxiety has subsided in intensity. Moreover delusions of relatedness, and disorientating phonemes with content to match have not increased. Thus the intensity of the basic phenomenon, namely anxiety, runs in parallel with the range of other symptoms; the decline of these phenomena is to be expected, in a similar sequence. (In fact the patient became healthy in the space of 3 months after the demonstration, and has remained so for 2 years since).