Gentlemen!

The factual material that I have presented to you so far allows us to put forward a few general observations about the course of the psychoses and their outcomes. We moved on from there to differentiate chronic and acute psychoses. However, closer examination of these differences of the course over time soon showed that acute clinical pictures are occasionally to be found in chronic cases, somewhere along their time line. This situation is to be explained by the fact that acute episodes interrupt the chronic course, but also by addition of symptoms that in themselves, or in their practical consequences, bring with them severe Affective states. We should always stipulate that a continuous course, uninterrupted by symptom-free periods, is a criterion to recognize a psychosis as chronic. We should not expect to include the so-called periodic psychoses amongst the chronic psychoses, since, in reality, they are recurrent or relapsing psychoses, even though recurrences follow so closely on one another that in practice there is no significant difference. In general, chronic psychoses have a worsening course, that is, they lead to ever-increasing disorientation. This is particularly true when acute psychoses are separated from actual chronic psychoses, and cases of chronic mental disorder remain as I did earlier. In contrast to such cases of chronic psychoses, we can also define—as we would in general medical parlance—an improving course, provided the condition does not remain stable and unchanging, which is rarely the case. The improving course is then synonymous with gradual recovery of orientation, without it ever being fully achieved.

We must subdivide acute psychoses according to their time course into peracute, acute, and subacute psychoses. This distinction is of practical importance; however, we would only apply it when we deal with a clinical picture of acute coloration, which has developed slowly over time, to distinguish it from chronic psychosis. Thus, for example, paralytic psychoses usually develop subacutely. The differentiation of a peracute illness onset is less useful in practice, but finds its use in the so-called transitory psychoses. If you want to include here all cases where a severe clinical picture emerges within 24 h, then a significant percentage of all acute psychoses would be excluded. Of course prodromal symptoms, which are purely physical in nature, such as insomnia, lassitude of limbs, headache, indisposition, etc., must be omitted. Included amongst the rarities, are cases such as the previously mentioned (p. 186) Miss v. F. in whom an acute psychosis existed in full force from one particular instant—her awakening from sleep—but then continued on an improving course. We might properly consider such cases as apoplectiform, and thereby rare cases would automatically come to mind of polyneuritis, within which the same clinical picture intrudes. Moreover, these very acute-onset cases remain for some time at the peak level of illness, before their intensity diminishes. Of course, their outcome can also be death or dementia.

However, the course just described is still continuous. There are, however, not only continuous courses but also remitting and intermittent ones. In effect, we should call the course intermittent if there are one or more lucid intervals. In this sense, one could therefore refer to many cases of mania and confused mania as having intermittent courses. However, in practice, intermissions of the shortest duration are best ignored. We should then identify an intermittent or recurrent course only in cases in which a series of individual attacks succeeded one another, as is the case in hyperkinetic forms of menstrual psychosis. The intermissions here must be included in the actual duration of illness, especially since they are often beset with states of physical and sometimes mental fatigue. There is no question that such intermissions do not merit the term ‘intermission’ [Ed] in its strict sense, if they do not lead to full insight into the illness. Such cases would therefore be examples of a remitting course. Sometimes, chronically worsening psychoses show an intermittent start. For example, two distinct instances of a delirious state formed the precursor to primary major and consecutive delusions of persecution in a 35-year-old man who was not a drinker. In such cases, insight into illness gained in the first intermission was lost in subsequent ones. Here the course is remitting or, probably more accurately, rising in a staggered fashion. The remitting course often both rises and falls in a staggered way. Most anxiety psychoses are examples of such a remitting course, in which anxiety, and the autopsychic disorientation based upon it, usually exist in a persistent fashion, but are increased in attacks that lead to allopsychic disarray and corresponding ideas of allopsychic anxiety, in the guise of phonemes. This fluctuating—perhaps ‘remitting’ [Ed] would be better—course of anxiety psychoses has been mentioned repeatedly.

Gentlemen! In remarks just made, you will recognize the effort made to express the course of psychoses in part in the form of a curve. It would be a great step forward if we could obtain a rapid overview of such illnesses, which often stretch out over years, by producing a true disease curve, as an immediate focus for our attention. However, we must not hide from the difficulties in the way of such an undertaking. What criteria could guide construction of such a curve, if we want to avoid being quite arbitrary? Surely it would have to make exclusive use of tangible objective data. We find such data for example in body mass, and from my comments about the remarkable influence of mental illness on nutrition and metabolism (p. 100), you will not be particularly surprised if I tell you that the closest method of constructing such a curve is to use data on body mass as the ordinate. In fact, in a large number of cases, a curve constructed in this manner seems, at first glance, to match the disease curve surprisingly well—surprisingly, in so far as all emerging clinical variations in the course seemed to reflect inverse variations of the bodyweight curve [W]. Moreover, in acute episodes of chronic psychoses, this behaviour often comes strongly to the fore. Furthermore, it is often seen in recurrent courses of acute psychoses, for example in hyperkinetic motility psychosis or wrathful mania, that the bodyweight curve rises in a staggered way in intervals between attacks, while, at the same time, clinical forms of these attacks become milder, until the continual increase indicates definite recovery. However, deviations from this behaviour are [Ed] observed, even when not explained by inter-current illnesses or accidental complications, although frequent occurrence of such complications often hinders evaluation of bodyweight curves to measure a disease trajectory. A glance at chronic psychoses also teaches us that often enough the patient’s general condition is in no way mapped out in his suffering. Certainly therefore, we can acknowledge the practical value of the bodyweight curve as a mirror image of the disease curve for most cases of acute psychoses; but we should also not overestimate it and, above all, should admit a priori [W] that its scientific value is provisional and doubtful.

Moreover, theoretical considerations point us in other directions. In psychoses, as everywhere, we must obviously differentiate between intensity and extent of the disease process. Accordingly, a special curve must be constructed for intensity and extent for each case. What we have to understand by extent, is not hard to specify: It is the number of elementary symptoms which can be specifically identified in the resulting changes in content of consciousness; or, in other words, the scope and degree of disorientation. We know of psychoses whose extent is consistent throughout their course, and in which disorientation varies only in degree but not in extent. Thus Affective melancholia and pure mania persist as the same symptom complexes throughout their entire course. Accompanying disorientation (in other words belittlement of self, even to the point of delusion), or the hubris of grandiose delusions, remain limited not only to the area of personhood, but also to an unchanging and specific line of thought. There are essential variations in the degree of orientation here, and these depend in distinctive ways on the intensity of Affect. The name we give—autopsychic anxiety ideas (we might also call them ‘misfortune ideas’, undermining ideas of happiness) [Ed]—shows their derivation from an Affective state. As a result, a curve of intensity [W] suffices in such cases, to represent the course of the illness completely. In contrast to such cases, we see gradual summation of elementary symptoms, and substantive changes in psychoses proceeding in a purely chronic manner. Here a curve just of extent [W] will reproduce completely the progression of the disease. We could also express this relationship by setting in one type the curve of extent, in the second that of the intensity lying parallel to the abscissa.

Gentlemen! From the overview that I gave you at the conclusion of the clinical presentations, you will have seen that cases that I differentiated as the so-called ‘basic forms’ [Ed] or ‘simple psychoses’ [Ed], present mainly the same complex of symptoms throughout their entire course. For all such cases, the intensity curve is of predominant importance. However, this applies only in a broad sense; to be specific, there are many variations in extent. I mention only cases of intestinal somatopsychosis that increase rapidly to almost total disorientation over the entire body. For the vast majority of acute psychoses it would therefore be essential to plot both curves. Take the above-mentioned example of acute hallucinosis: There the course is summarized from two curves of totally different shape, following the overall impression given earlier. The acute onset of illness corresponds evidently to its greatest intensity, while the desperate decision of suicide can be viewed just as an external index of this. During hospitalization, and probably as a result of it, intensity tends to diminish significantly; and it shows occasional elevation, related to external causes such as a change in circumstances. Finally, the Affective reaction is progressively lost, and the intensity curve approaches the x-axis quite rapidly. The summary representation of the disease process given above could not take such a pattern into account; it appears to correspond to a one-sided consideration of the curve of extent of disease, whose shape tends generally to be a reciprocal of the intensity curve, that is, the worsening form progresses and only later, more or less rapidly does it approach the abscissa. From this example we also see what yardstick we need to represent the intensity of the illness. The Affective reaction is the exclusive consideration for this purpose: Its variations in degree give a good general discrimination. Whatever fear, unhappiness, despair, or bewilderment present is forced on each observer without further thought. I must point out only that a deeper sense of our curve of intensity curve requires that all levels of these different Affective reactions are to be conceived as expressions of the one basic Affect for all acute psychoses, namely disarray. I even believe that the abnormal euphoria of manics is due in part to disarray, but surely in other manic states, such as manic allopsychoses, the evident joy, and inclination to laugh, can often be attributed to the patients’ finding the supposedly changed situation funny. However, I would specifically like to emphasize that those Affective states which cannot be attributed to disarray must remain unused in constructing the intensity curve. I would prefer deliberately to omit more specific information about the shape of the two curves, and their relationship to each other in the various psychoses that you have studied in greater detail, because this part of our clinical task is still very much under development. I limit myself to suggesting that the curve of body weight depends predominantly on the curve of intensity, and prognosis of individual cases seems related to the relationship of the two curves to each other.

Gentlemen! I have yet to mention a peculiarity in the curve of extent that is essential to characterizing all those psychoses in which it is of primary importance: We have seen above that the majority of acute psychoses initially take a worsening course. For the curve of extent, this usually amounts to summation of symptoms of illness, so that we can speak of an accumulating course [W] of the disease. You will remember my description of composite psychoses. Consider these now in relation to their curves of intensity and extent: The purest type of composite psychosis is seen when the succession of clinical pictures has come about not through an accumulation of symptoms, but through some manner of mutual separation of different symptom complexes. Apart from a cumulative course, we must therefore differentiate a substituting course [W], and see that the latter relates only to the curve of extent. The difficulty to which I already drew attention in the context of composite psychoses, was that a later phase of the illness can simply be regarded as augmentation of an earlier phase. This appears in a special light, given this consideration. Perhaps it would even be correct to restrict the concept of composite psychoses solely to cases characterized by substitutional behaviour in the curve of extent. One could perhaps use different colours on the curve, to indicate the significant diversity of symptoms in these cases.

Gentlemen! I come now to a brief summary overview of the outcomes of psychoses [W] and take the opportunity to draw attention to a point that I have never found emphasized sufficiently. Psychoses, if not conceived too narrowly, are so common that at least two per thousand of the population are undergoing treatment in asylums, these belonging to the most hazardous and truly life-threatening illnesses. Even the statistics of large asylums, provided that they are not exclusively secure units for chronic cases, reveal mortality of about 10 %. If we add the myriad of suicides carried out outside institutions by psychiatric patients who were not hospitalized at the time, we get a mortality figure approaching that of the most difficult surgical procedures. Outcome in death is intrinsic to all acute mental illnesses, a fact which, a priori [W] must remain as part of one’s reckoning. This outcome is sometimes brought about by incidents arising from the unpredictability of the sick, such as self-harm, but at other times as a result of the illness process itself, as I have repeatedly stressed, along with many examples. Fever is sometimes present in such cases, but one can often find—even at autopsy—no explanation other than the disease process in the brain itself. Between these two extremes lie a large number of cases of illness in which death is to be explained as a result of insufficient nutrition, lack of sleep, and continued restlessness—that is through inanition and resultant wasting away. Finally, wound complications, and internal illnesses should be mentioned.