Gentlemen!

You will recall how strongly I have always emphasized that our clinical knowledge of the psychoses is still very incomplete. You must also bear in mind that the cases I present exemplify most of the more frequent types of illness; yet, taken together they do not constitute the majority of the main types. In other words, the more complicated and therefore less familiar cases predominate in number. The principle that has guided me in this selection is well known, and readily understood, namely to serve teaching purposes. Thus, you had to be shown simple cases, composed of a few elementary symptoms, where we could gain as full an understanding as possible. For us, they form the foundation of a theory of illness, to which we must refer continually in order to understand more complex cases. In this sense we could designate types of illness considered so far as fundamental forms of psychosis. It is not my intention now to attempt to describe just those cases which extend beyond the simpler situations: However, I cannot neglect a few brief comments on the perspective you will have to use in evaluating those cases which predominate in practice. Obviously, we should not attempt to force them artificially into some kind of schema, even if it be one like ours, which has been tried and tested. Nevertheless, our scheme does so much to help analyze presenting symptoms in these complex cases.

Firstly, I remind you that, between any two familiar forms of acute psychosis, we have already found many transitional cases. These are amongst the simplest examples of those more complicated mixed psychoses, [W] as we shall call them. Thus borderline cases of anxiety psychosis and Affective melancholia, which I briefly outlined earlier (p. 149), are familiar to you. Because of their high frequency, they deserve to be emphasized. Less common are cases of delirious anxiety psychosis, briefly mentioned earlier (p. 147), fairly pure cases of acute autopsychosis whose content was one of anxious belittlement, in which essentially only the course and contribution from the projection system are borrowed from Delirium tremens [W]. The clinical picture of agitated melancholia, which I likewise characterized for you as an anxiety psychosis (p. 148), is perhaps amenable to a uniform explanation, if we assume that the frequent occurrence of ideas of anxiety leads to loquacity and flight of ideas. In any case, coincidence of these two manic symptoms with anxiety psychosis is quite exceptional. Moreover, agitated melancholia corresponds to one of the more frequent illness types. These cited examples represent mixed forms, which wholly or partly include autopsychic disorientation, so that they always remain within the larger illness group of autopsychoses.

As a transitional case between autopsychoses and somatopsychoses, we have become acquainted with the example of hypochondriacal melancholia (p. 162). In Affective melancholia, the ‘overvalued idea’ [Ed] is a feature taking its content from bodily consciousness, and whose derivation from a hysterical sensation is usually unmistakable. In depressive melancholia, the somatopsychic element predominates by far, whenever it is derived from severe hypochondriacal mental illness (p. 262). In both cases, we can assume that other sets of symptoms have a conditional relationship, but in opposite directions. Thus, in hypochondriacal melancholia, the hypochondriacal element appears as a consequence, while in depressive melancholia, it becomes the origin of the autopsychosis. In hypochondriacal mental illnesses, we regularly encounter similar mutual conditionality based on the fact that the symptom of anxiety, which is seldom absent, can have as a consequence, corresponding autopsychic ideas of anxiety, which lead to autopsychic disorientation in the form of belittlement. Thus we conclude that somatopsychoses occur only rarely in pure form, but usually fit the concept of ‘autosomatopsychoses’ [Ed], and thus really belong among the mixed psychoses. You will find that in my presentation of the somatopsychoses I always took this into consideration. In contrast, I deliberately said nothing about another combination, which is seen no less often. It consists of that form of disorientation which often occurs quite acutely, and which we can designate as ‘hypochondriacal delusional state of persecution’ [Ed]. Moreover, there exists internal connection between somatopsychic symptoms, and (in this case), allopsychic symptoms, due partly to simple explanatory delusions, and in part to the elementary symptom of somatopsychic delusions of relatedness, which, at the time, we categorized as new-formed associations. In acute psychoses, the latter connection evidently predominates, and often does so, either just initially, or entirely, even in cases which lack autopsychic disorientation via belittlement. We include such cases amongst acute allosomatopsychoses, a well-defined hybrid between allopsychoses and somatopsychoses. In other cases, this combination develops on the same basis, while anxiety soon reaches a very high level, with disorientation in all three areas of consciousness, and characteristic content which is fantastic, and at the same time a hypochondriacal, menacing delusional state. This is often a very acute clinical picture of total sensory psychosis, usually associated with a huge numbers of hallucinations, fear of being touched and blind defensiveness. In the autopsychic area, it often comes down not only to ideas of belittlement, but also to the opposite picture of grandiosity; and the disorientation often has a tendency to gravitate in the latter direction, while belittling ideas, in the guise of phonemes, are strongly rejected, and the Affective state of disarray prevails in this respect. The helpless compulsion towards movement described above (p. 232) is peculiar to all these cases. As a result of the disorientation, the most diverse acts of disarray may occur: among them, running about blindly; breaking windows; attacks on people round about; and self-harm in most diverse ways, according to the location of hypochondriacal sensations; finally, we should explicitly mention the refusal of all food. Differentiation of the clinical picture described here, is mainly made in the motor domain, in that we can include only cases in which actual motility symptoms are entirely absent. The clinical picture of acute total sensory psychosis, with content of fantastic hypochondriacal menacing delusions, occurs quite often as very brief attacks, lasting only a few hours or days, based either on intoxication or degenerative processes. Chronic alcoholism is particularly involved in the case of intoxication; in the case of degenerative states, those with hysterical and epileptic disposition make up the majority of the so-called transitory psychoses. [W] Prior head injuries predispose to this. For longer states of this sort, I am unaware of any deeper aetiological relationship. I need not mention that this is always a life-threatening situation. If maintained, a more-or-less severe state of exhaustion, with memory deficit, tends to follow, which may merge into convalescence. A paranoid stage is not observed. With respect to the course of acute fantastic hypochondriacal menacing delusional states, their development up to their peak may be reached within a few quarter-hours in cases of transitory psychosis; in other cases it develops over a period of a few weeks, from an initial hypochondriacal stage, in which delusions of relatedness with hallucinations in all the senses occur, as well as explanatory delusions of most diverse kinds. Even for these cases however, as the severe state endures for longer periods, a predominantly sensory character and evident worsening course tends to develop, mainly with motor symptoms and of various hyperkinetic, parakinetic, and akinetic types, which can lead, at this stage, to profound exhaustion and death. I have seen many such cases, mainly amongst those with a severe hereditary predisposition; they deserve to be called acute progressive sensory psychosis [W]. One case of this kind, involving a 40-year-old kyphoscoliotic labourer with hereditary loading, not addicted to alcohol, ran through this course within 2 months, during which the patient lost 24 lb in body weight despite extensive feeding during the last week. Moreover, the majority of cases of transitory psychosis tend to be accompanied by more specific motility symptoms.

Gentlemen! The picture outlined above of acute fantastic hypochondriacal menacing delusional states is amongst the most severe Affective states we know. When it has lasted somewhat longer, often even after a few days, the general finding is that it leads to a degree of damage of such severity as is found elsewhere only in the most severe general physical illnesses. Shrunken features; general muscular tremor; hoarse, rasping voice; dry, scaly coating on the lips, tongue and teeth. Quite often, and probably then as a sequela, signs of incipient blood decomposition or severe trophic disorders foretell impending demise. Disorders of nutrition can also find a basis in pathological anatomy, for example as inflammatory foci in the anterior horns of the spinal cord, with multiple gangrenous areas in skin (autopsy carried out by Cohnheim). It is mainly such cases, which other authors have called Delirium acutum [W]. However, we cannot acknowledge this as a special sort of illness, but recognize only the readily comprehensible consequences of a particular clinical picture, with acute features, rapidly taking a severe toll on available energy. Such extremely severe cases are fortunately quite rare, although a proportion of them also present with additional symptoms from the projection system, so that they are claimed as cases of the so-called ‘galloping paralysis’ [Ed]. Moreover, you would be wrong if you thought that total sensory psychosis always had characteristic contents of fantastic hypochondriacal menacing delusions. That is by no means true, as it shows up mainly as mixed cases, with only moderate levels of Affect, and with delusional ideas whose content covers various types of partial disorientation, differing greatly amongst individuals. For example, somatopsychic disorientation may be limited to delusions of pregnancy, autopsychic disorientation to accompanying ideas of having sinned, and allopsychic disorientation restricted only to certain time periods and certain relationships, so that the prevailing situation can still be recognized correctly. Phonemes and explanatory delusions then form accessory parts of the clinical picture [1]. At other times, partial disorders of orientation are found in isolation, at least in their not being mixed simultaneously with significant motility phenomena, which usually endow the explanatory delusions with a definite magical aura in their content. You will find several examples of this type, characterized, I should say, by a relatively rapid favourable course, described as mixed acute sensorimotor psychoses, among the patient demonstrations from my clinic [2].