Gentlemen!

These lectures can hardly be intended to introduce you to the practical medical specialist training course for the asylums. Whoever wants to dedicate himself totally to our specialty is of course expecting to spend a considerable part of his life in mental institutions, and among mentally ill people, a task that in some respects you can imagine is not sufficiently challenging, but also not sufficiently gratifying and interesting. However, each of you will, at some time, be in a position of deciding on the placement of a patient in a mental hospital, or having to issue a certificate that health has been regained, and it is therefore imperative to give you some orientation on practical issues, including the specific tasks of the asylum, and the simulation and dissimulation of mental illnesses.

Let us not underestimate the fact that a major source of evidence in psychiatry is language, in other words, the messages that patients themselves provide about the content of their consciousness. Clearly, it is only in this way that you can learn anything more complex about the thought processes of a patient. A prerequisite for this is either the goodwill a patient shows towards communication, or in illnesses such as mania, when there is an intrinsic desire to communicate. If such prerequisites do not apply, it can happen that patients remain intentionally silent for weeks, months, even years, or speak only on exceptional occasions. Amongst the best proven ways of bringing such patients to speak, is a clinical presentation, although of course you should be prepared for all manner of surprises and, under some circumstances, even quite dramatic turns to the conversation. This deliberate silence [W] naturally has nothing in common with mytacism, the incapacity to speak. Usually, it involves negative, suspicious, and embittered patients, overcome by ideas of persecution and grandiosity—those paranoid states which have already been mentioned. On the other hand, it may happen that the silence is deliberately restricted to those points that a physician needs to know, in order to assess the mental illness; that is, the patient dissimulates his delusions. Most frequently such dissimulation [W] occurs in patients who have long survived in a calm state, after having previously come through an acute period of illness. Having now regained the discretion that is necessary to monitor their statements, they are inspired by a lively ambition to rid themselves of restrictions to their freedom, that is, life within a mental institution. They therefore strive, with greater or lesser success, to deny their delusions, once they have found out what ideas a physician might regard as abnormal; this having been learned in any favourable circumstance, such as their presence during examination of similar cases. However, in such patients, it is always possible, by asking appropriate questions, to determine the truth. For this purpose, the method consists of provoking the patient’s judgment about his symptoms, as previously observed, and thereby determining that actual insight into his illness—the main criterion of health—is still missing. If the patient’s silence persists in a stubborn manner, on points that matter, then you cannot consider him healthy. Sometimes, it turns out that the patient cannot give the information you need, because, as part of his illness, a memory deficit exists; and then, naturally it is not required that the patient admits them. Generally, patients seldom deny their delusions; and even where it seems appropriate to them to do so, they do it only reluctantly, and are easily driven to adjust the boundary where expediency might prevail rather their delusion. Compared with such frequent cases, it may happen, albeit rarely, that a patient with early-stages of a chronic worsening psychosis dissimulates his delusions, at a time when he is himself still unclear how far the intrusive ideas and alleged observations correspond to reality. He declares this or that strange expression he had used, to be a joke or a misunderstanding, or he attempts to give it a more harmless character. In the end, he probably becomes indignant, and denies the questioner the right to meddle in his affairs. In such cases, reliable information from the family or other persons close to the patient is essential in order to justify crucial decisions that the patient be detained against his will, for observation in an institution. Such information could be about comments and actions that have raised suspicions of mental illness. A case like this is before me at present, where my encouragement led to the patient being admitted voluntarily into the institution, where however, his trust was lost on the very next day, when I had to refuse his discharge; from then on, he refused to give any further information. After that, he existed only for his discharge, and finally sought to force this through, by refusing food. Under the circumstances, I was extremely embarrassed to use force, but it was unavoidable, and it was therefore, against vigorous resistance, that artificial feeding was enforced several times, at which point, he decided to give up his resistance. After several weeks had elapsed the family then decided, much against my advice, to remove the patient from hospital treatment. Apparently they were right, for there was no further recurrence of the delusions he had expressed previously, and he resumed his earlier work in a business. Even though it appears that, with a history like that, the doctor got it wrong, yet this very case is the most irrefutable evidence that in all similar cases no greater benefit can be rendered to the patient than his being forcibly transferred to the mental institution. To be specific, when, in such cases, recovery is possible—relatively so, as it appears in this case—it is brought about firstly by the fact that the morbid ideas were overcome by his own forceful protests; and there is no more powerful protest against delusions that are not completely fixed, than to realize that they inevitably lead to his being detained, against his will in an asylum for the insane. Thus the patient had to thank his undeniable improvement, perhaps even his healing, had this been achieved meanwhile, mainly to the fact of his transfer to the mental institution. (I must now correct these lines, written about 10 years ago. The patient’s mytacism resumed after a year, and later he became incurable.)

After such experiences, we must pose the question: To what extent should everything that is said by a patient claim the value of an objective symptom? Rather, are not utterances of patients completely dependent on their volition? Under some circumstances, could not a healthy person imitate the speech of a mentally ill person; or, apart from this case, could not a patient intentionally say things other than what he is actually thinking? Our standpoint here is briefly as follows: Language may indeed be influenced very much by volition; yet it still remains a function of consciousness, that is, of that brain activity which we have to examine. This function may not always be so simple, so that the willingness of a patient cannot easily be assumed to comply appropriately with questions addressed to him. Nevertheless, with proper conduct of the physician, and as soon as the patient’s trust is won, only seldom do we find that a mental patient’s words are at odds with what is in his heart, and intended to mislead the doctor. Where a patient is prone to violent Affective responses, then the self-control that would be necessary for this approach is already ruled out. Usually, the rest of the patient’s behaviour enables a reliable judgment to be made about whether or not he comes to meet the doctor willingly. In some cases however, the particular decision on whether, and to what extent, a mental patient is simulating, can be made only with great difficulty. Two aspects should then not be ignored in the assessment. Firstly, there are mentally ill people who confront their nonsensical intrusive thoughts en masse [Ed] with their own quasi-criticism, so that, for example, they even laugh about the nonsense that they produce in given moments. These patients usually belong with those otherwise characterized as motility psychoses. The content of the delusions is often religious, characterized simultaneously by both fantastic coloration and repetitiveness. The repetitiveness often rises to the point of verbigeration. The rest of these patients’ behaviour dispels any doubts over whether they had been serious about their delusions, even after achieving success in getting them to confess that they had just been talking nonsense. Of course they then tend to reinforce what they said: It just came to them; they could not explain it themselves. This phenomenon has a certain similarity with the compulsive speaking we encountered in the same class of patients. The second case is more difficult, where usually even external circumstances raise the suspicion of simulation. This usually involves prisoners, in whom there are suspicions about whether it was true mental illness, or simulation; and they have therefore been sent to the mental institution for observation. Experience teaches that most of these individuals are [Ed] actually mentally ill, even when they are apparently simulating. Pure simulation without existing mental illness or feeble-mindedness is rare in itself, so that even the most experienced alienist sees only isolated cases. If you consider that a mental patient usually experiences the inconvenience of imprisonment with all the embarrassment of someone who is mentally healthy, and therefore takes advantage of feelings of mental illness coming over him, that fact seems like putting a gift into his hands. At least the prospect of being transferred to a mental asylum holds no terrors for him, and therefore has no power to motivate his self-control. If this is so, a few days of indulgent, confidence-inspiring treatment in a mental hospital usually suffices to allow the clinical picture to emerge in purer form, and for arbitrary excesses to disappear. Of course, there often remains a disconcerting clinical picture, such as one that does to fit any form of illness, or crude violence, or all manner of shameless acts, coprophagia, etc. However, such modifications become understandable to us, in that, in such cases we are dealing with morally depraved and neglected people, coming mainly from families where they were forced to become criminals. In other cases, it turns out that, although mental illness is simulated, it is nevertheless based on either congenital or acquired feeble-mindedness, often complicated by epileptic seizures. Nothing is as hopeless as wanting to turn around malingerers of such kind by coercive measures such as starvation, etc. Leaving aside these two possibilities, the number of remaining true malingerers, as said above, is very small.

Institutional treatment [W] has the following tasks to resolve: