Onset in Acute schizophrenia 1947 inicio de esquizofrenía aguda.pdf

7/27/2019 Onset in Acute schizophrenia 1947 inicio de esquizofrena aguda.pdf

1/9

REPRINTED FROMPSYCHIATRY: JOURNAL OF THE BIOLOGY ANDPATHOLOGY OF INTERPERSONAL RELATIONS

VOLUME TEN, NUMBER Two, MAY 1947WILLIAM ALANSON WHITE'PSYCHIATRIC FOUNDATION

1711 RHODE ISLAND AVE., N. W., WASHINGTON 6, D. C.


2/9

Anton T. Boisen*

THIS PAPER will attempt to show that the successive stages in the develoof acute schizophrenia bear a striking similarity to those of insightful thiThis similarity supports the view that the schizophrenic reaction should be sdistinguished from certain other formations with which it is commonly assoformations which obscure its true significance as a manifestation of nature'sto heal, analogous to fever and inflammation in the body.1

Let me begin with a case which exem-plifies the schizophrenic reaction, a caseunusually free, from malignant involve-ments.2 The patient in question, Oscar 0.,was brought to the hospital after an at-tempt at suicide. He had been found inhis home with the gas turned on and bothwrists cut. According to the commitmentpapers the motive was self-sacrifice. Hewanted to relieve the world of its sins.The onset of the illness, according to thepatient, was "quite longit was a wholeweek!" The wife states that she noticednothing wrong until two days before. Shethen observed that he had become self-absorbed and unable to sleep. There hadbeen a previous commitment 13 years be-fore. Then also the onset had been sud-den, the disturbance severe, and theduration brief.In appearance he was a stocky man of53 with barrel chest and heavy muscles.When first seen, he had just emerged fromthe disturbed condition. He was eager tounderstand what had happened to him,and he talked frankly of his experience ina sensible and matter-of-fact manner.He was a native of Sweden, the second

2 This case I have used before in an article whichappeared in the Elgin Papers for 1932 and inanother article in the Crozer Quarterly for 1940.

in a family of nine, seven of whomboys. All of the children lived to mand have given a good account ofselves.He considered himself to have bfairly normal boy. He went throughgrades in school without repeatingrades, but he hated school and hislastic standing was only fair. In ahowever, he was not so dumb. Helick any boy in his room. After l

school, he served an apprenticeshipmechanic; then at the age of 21 he wsea. After seven years of roving hedown in this,country, and at the31 he married. His vocational recorexcellent. His trade, however,highly specialized one, and the assigof jobs was determined by the uniothis reason he was often idle.He talked frankly of his sexments. There had been the usual difwith masturbation in the adolesceriod, but he thought it had not beensive. While at sea he had sometimeswith his mates to houses of prostitbut apparently he had kept withibounds of respectability as judgedgroup. His wife, at the time he mewas a working girl. He became inte* A.B. Indiana 97; M.F. Yale Forest School 05; B.D. Union Theological Seminary 11; M.A. HarvD.D. Washburn College 38. Instructor Romance Languages Indiana Univ. 99-03; Forest Asst. U. S.Service 05-08; Field Investigator Dept. Country Church Work, Presbyterian Board of National11-12; Rural Pastorate 12-17; Secretary Y.M.C.A. A.E.F. 17-19; Supervisor North Dakota RuralInterchurch World Movement 19-20; Chaplain Worcester State Hospital 24-31; Lecturer and RAssociate Chicago Theological Seminary 25-42; Instructor Boston Univ. School of Theology 29-31; CElgin State Hospital 32-; Earle Lecturer Pacific School of Religion 42-43. For bibliography, see ReLists section of this issue. .1Cf. Boisen, A. T., The Form and Content of Schizophrenic Thinking, PSYCHIATRY (1942)also Exploration of the Inner World (Chicago, Willett, Clark & Co., 1936) chapter 1. For ainterpretation, see Sullivan, Harry Stack, Conceptions of Modern Psychiatry, PSYCHIATRY (1940)particularly pp. 69-82.

[159]


3/9

agrees. ne ge s e mpress on, ow-ever, that the home life is somewhatmatriarchal. The wife is a quick, attrac-tive, business-like person, accustomed ap-parently to having her own way. She saysof him: "He says that anything I say isall right." He says of himself that he hasgood, will power and that whenever hewanted to, he did not hesitate to assert it.The patient and his wife were broughtup in the Lutheran church. Of his earlytraining he says that he was dragged offto church and Sunday school and that hehated it. He never did "grab anything inreligion." He claims to be something ofa free-thinker. In politics, he is inclinedtoward Socialism. In religion, he camefrom Missouri: he wanted proof beforehe,'was ready to believe. Neither he norhis wife were active in church.He was quite ready to talk of his ex-perience and allowed me to get it downpretty much word for word. Here is hisaccount:

I must-give it to you in order. You can'tunderstand unless we go back to. the begin-ning 13 years' ago. You must know how thewhole thing started, how I made a sort ofbet with God.I was at a Socialist meeting one night. Aman there spoke of Jesus and of his givinghis life for others. He asked if there were notmany others who would be willing to do that.That night I was thinking about what theSocialist speaker said and that I would gladlygive my life for my family alone. In the nightI was waked up and a voice said, .'You mustbe put to the test to see if you will really giveup your life.' It seemed/as though God wereright in front of me and the voice seemed tobe God's voice, and words from the Biblecame into my head. I began to feel verynervous. It seemed as though something wasgetting into me. I did not tell my wife. I feltshe would not understand. I got up and ranout into the street in my underwear. Ofcourse that was a very strange thing to do, butit was just like the old Greek who found outhow to weigh a ship. He was in his bathtubat the time the idea came to him, but he gotso excited that he got up and ran out withoutanything on. You get an idea so big it justcarries you away.I think it was the same night that bloodcame into my mouth, and something said it

out a wee a ter t at was sent^hospital. After that dream I was nI had a feeling like when they bind uarm and give you a blood test. I wasfilled up. It was a queer feelingsoyou don't understand what it is. I hfeeling that there .were two sides andhad to go to one side or the other in oget salvation.In the hospital I was put in a strait.The first night I had. a dream. I seebe crucified, and the whole room was devils. They were trying to hurt mewas full of power. You see I was ilirium. I dreamed I was dead. I drewas lying in the grave just like JesusIn about three days my mind camand I was released at the end of threeI got along very well after, that. I hadwork and there was nothing to worryDuring the last three years work hascarce and there has been plenty of' tthink. No, I had not been thinkingabout religion. My wife was told at tpital that the trouble came from readiBible; so I put the Bible in the attic. Iwant to make her nervous. And I dito church. ;The last attack began when somethime to go and get the Bible. I hadthen to pray to God. I had been feelinsome and I had it in my mind that theGod. Then it came to me that I had ainstallment to pay. I had to finish payibet with God. I' came then into a stateSomething said to me, 'Are you wilcommit suicide?' And it was just liketo do it. I turned on the gas. Thatmy wife. Then I slashed my wrists,one daughter and the other for thedaughter. But everything I have donecame to a good end, and I have thethat this will too. I just felt that I hait to keep my promise. I have the feelithat I am a new man. All this is over.done my part.No, I didn't hear anything. It's juwhen you sit and think. Something coyou. Sometimes it comes quick jusomething talk to you. I suppose itfrom God. I can't see any other explaYes, I did say when this came onjust like I hypnotized myself. Whenwith a doctor, I talk about self-hypnA doctor understand that. He don'tstand about religion.Did I think of myself as Christ?guess I did. That was before I undeYou get happy and you wake up andyou are it. You get puzzled as to who y


4/9

ou was go ng r g e way -you was.don't need you to preach. I have other men Ican send to do that.''"' This case shows th6 schizophrenic re-action with unusual clarity and complete-ness. Its representative character is ap-paient when we- review its successivestages in the light of a statistical study of75 other cases likewise characterized bysudden onset, severe disturbance, andrelative freedom from complications.

PERIOD OF PREPARATION OR FRUSTRATIONIn,all of our cases we"find evidence ofsome unsolved problem relating to thepatient's' role in lifea problem whicharouses intense emotion. Nearly alwaysthis problem involves, some sense of per-sonal failure and guilt.3 It has usuallybeen on the patient's mind for many yearsas a source of distress and uneasiness until

finally, in cases of this type, there comes adesperate attempt at solution..What the problem was in the case ofOscar 0. is suggested by the questionwhich precipitated the disturbance. TheSocialist speaker asked, "Are there notmany men who are willing to give theirlives for others?" The fact that this ques-tion touched off an explosion may betaken to. indicate that it bore on someproblem with which he was already

grappling. His immediate response was:"Of course, I would gladly give my lifefor my family alone." As a matter of facthe had been doing exactly that. His en-tire life had been organized around hishome. He had been carrying out quitefaithfully the. professions of undying de-votion which he had undoubtedly madeas a lover. But that night he was wakedup and a voice said to him, "You must beput to the test to see if you will reallygive up your life." Clearly there was

2 Cf. Boisen, The Sense of Isolation in Mental Dis-order: Its Religious Significance, Ame'r. J. Sociology(1928) 33:555-567; The Problem of Sin and Salva-tion in the Light of Psychopathology, J. Religion(1942) 22:288-301; and Exploration of the InnerWorld (reference footnote 1), chapter 6.

,there .was a situation here whichmanded, attention. It will perhapsseem farfetched to suggest that histionship with his wife had involvedtain therapeutic aspects. .. It. had,something in the nature of a "tference" involving dependence upfinite love object which needed now t"broken up," or "resolved."*, This case would then differ.from,majority of such cases in that.,thesituation did not involve the sense ofsonal failure and guilt but rather award step in his development pr mation. ; , . . . . . , . ' , . ; , . ' . . ; ' . . . [ . , : ' . , , ; . . ' ;i . , ; PERIOD OF NARROWED ATTENTION

, ' . . . ' ' j f | , , f . - , . ; ,Asked if the. disturbance came ondenly, Oscar 0. replied: ' "No, it towhole week, and it took a whole weefore.". We would say that it came onsuddenly. At the time of the secondmission, the wife did not notice anytout of the way until two days before.had then become self-absorbed andable to sleep. In many of our casesinformation regarding the period of ois deficient, but in 42 of them therclear evidence of a period of preocction lasting from a few days to aweeks. In more than half of these, tis mention of praying and readingBible, in 15 of preoccupation, in 1sleeplessness, in 4 of crying spells.cases the patient had become absorbewriting. A classic description of this sis to be found in John Bunyan's GAbounding to the Chief of Sinners:

By these things my mind was so turthat it lay like a horse leech at the vein.it was so fixed on eternity and on the thabout the kingdom of God, that neithersures nor profits, nor persuasions nor thrcould loose it or make it let- go its hold;though I speak it with shame, yet indeeda certain truth; it would have been as diff

4 For an illuminating discussion of this point,Hocking, -W. B., Human Nature and Its Re-ma(New Haven, Yale University Press, 1923), ch42.


5/9

characteristic as to justify a question asto whether Oscar O.'s suggestion regard-ing autohypnosis may not be worthy ofconsideration. Certainly we know thatHindu holy men and others of the shamantype employ techniques for the narrowingof attention in order to induce the trancecondition.5AN UPSETTING IDEA

The patient states that he ran out intothe street in his underwear. Of course, heexplains, that was a very strange thing todo, but like Archimedes of old he had gotan idea so big it just carried him away.This is an explanation which will applyto many other cases. What the "big idea"was in his case is clear. He thought Godhad spoken to him, and he got a new con-cept of his own role. In most of our 75cases we find similar ideas. In 54 thereis specific mention of contact with thesuperhuman, and in 42 we find the ideaofcosmic identification.In the case of Oscar 0. the upsettingidea .was imparted by means of a "voice."It seemed as though God were right infront of him, and the voice seemed to beGod's voice. Questioned later regardingthis voice, he emphatically denied that itwas anything he heard with his ears. "Itwas just like when you sit and think.Something comes to you." So also in theother cases. The term voice is the onemost frequently used. It is employed 14times.' However, most of these patients,when questioned, will explain that it isnot something they heard with their ears.Many of them use other terms. Thus oneyoung man says: "I got such funny ideas.Things just popped into my head." Othersdescribe it as follows: "I got funnythoughts and felt myself under some sortof control." "I can't explain it. It wasjust the way I felt. . . :. It came to meas a revelation in a dream." "I got innerBCf. Coe, G. A., Psychology of Religion; Chicago,University of Chicago Press, 1916; chapters 11 and16. Also Weber, Max, Gesammelte Ausaetze zurReligionssosiologie (3 vols.); Tuebingen, J. C. B.Mohr, 1923; 2:169ff.

.came to me. I didn't have to searcwords. It was just as if I was commto say certain words I had never hebefore." Another says, "Communiccame to me from out of the ether.felt as though I were directed by sohigher than myself. . . . The word 'flashed across my mind. . . . I heinfinite voicethough not humasound." A woman patient said: "the inspiration, to write poetry. Iseemed to flow without my trying.weren't any voices. It was just ideacame to me. I got up one morning ao'clock and wrote my first poem.I put it together it was complete."on the idea came to her that shehave an immaculate conception. Sh"went into a tail spin." 'The point to notice is that the mnism involved in these voices is noferent from the 'insights' or 'inspiraof normal persons.6 The importansideration is what the voices say anfact that they are attributed to a shuman source.

PERIOD OF ELABORATIONWhat happens next is likely to dupon what the voices say. The moquent of all the ideas found in the sphrenic reaction is that of death: Wthis- in 50 of our 75 cases. When thiis passively accepted and no acticalled for, the picture is likely to bof depression or stupor. Seven ocases were stuporous and showed mpaucity of ideation.7When, however, the idea comes thhas an important role in lifeaftinitial idea of death which is accepa spirit of sacrificial renunciation

"An excellent discussion of the 'dynamisvolved is to be found in Coe's Psychology ligion (reference footnote 5), p. 193ff. SHutchinson, Eliot Dole, The Nature ofPSYCHIATRY (1941) 4:31-43.' According to August Hoch in chapter 5 ofStupors (New York, Macmillan, 1921), the irebirth is characteristic of stuporous patientidea was clear in one of the seven cases. Thewere inaccessible. .


6/9

n er e pro ess on ma es e er-encehas before him a problem involvingsome explicit production or decision in lifesituations. For months or years, it may be,this problem remains unsolved, this creativeintention unfulfilled. Attempts at solutionhave ended only in bafflement. But suddenly,usually in a moment when the work has beenabandoned temporarily, or when the attentionis absorbed by irrelevant matters, comes anunpredicted insight into the solution. As if'inspired,' 'given,' ideas arise which constitutea real integration of previously accumulatedexperiencean answer, a brilliant hypothesis,a useful 'hunch,' forming, it seems, a short cutto artistic or scientific advance. Exhilarationmarks such moments of insight, a glow or ela-tion goes with them, a feeling of adequacy,finality, accomplishment. The content of theseinsights . . . takes full form only in a laterperiod of verification and criticism.Thus the pattern of insightful thinking . . .involves a period of preparation, a period ofrenunciation or recession, a period or momentof insight, and a period of verification, elabor-ation, or evaluation. The process of creativethinking, is the cycle of these stages in mul-tiple and ever-changing emphasis.

That there is much similarity betweenthe process of creative thinking, as thusanalyzed, and that of the schizophrenicreaction is apparent. They have in com-mon the period of preparation or frustra-tion, the unpredicted insight which comes'as 'inspired' or 'given,' carrying authoritybecause of the way in which it comes andproducing a mood ' of exaltation and asense of finality.' In both there is theperiod of elaboration and criticism repre-sented in the flood of new ideas and aconsequent strain upon the critical facul-ties. "What is not so clear is the period of"renunciation" or "recession." We do findin a large proportion of our cases the re-nunciation of some longed-for hope andthe sacrificial acceptance of the idea ofdeath. It is generally following this thatthe idea of cosmic identification makes its"Varieties of Insight in Humans, PSYCHIATRY(1939) 2:323-332; The Period of Frustration in Cre-ative Endeavor, PSYCHIATRY (1940) 3:351-359; TheNature of Insight, PSYCHIATRY (1941) 4:31-43; ThePeriod of Elaboration in Creative Endeavor, PSY-CHIATRY (1942) 5:165-176; The'Phenomenon of In-sight in Relation to Education, PSYCHIATRY (1942)5:499-507; The Phenomenon of Insight in Relationto Religion, PSYCHIATRY (1943) 6:347-357.

a period of intense preoccupationcentration!. The explanationfound in Professor Hutchinson'stion that the period of recessionfinds in normal creative thinkintemporary giving up of the probdefence against emotional unbalfollows then that the schizophredition results when, in some dproblem-solving effort, the creatuitive forces take possession atpense of the organized self. Tdifference between the process ofthinking, as Professor Hutchinsoscribed it, and the schizophrenicis to be found in the intenselysignificance of the problem whicvolved, in the profoundness of ttion which is evoked, and in theperspective and balance.

THE SCHIZOPHRENIC REACTION MALIGNANT ' INVOLVEMENTSThis interpretation of schizmay help in the understandingis found in the complex of reactisented in most of our hospital casfour types generally labeled schizoare to be regarded as four differeof dealing with the sense offailure and intra-psychic dishthree of these are not problem-sol

actions but end results of malignaacter trends.In the simple type there are thin the face of accumulating diwithdraw into the realm of phantwishful thinking. This is a reactiotends to eventuate in progressivetion. Such a process may be an ione, unmarked by any stormy eFrequently, however, patients of tbecome aware of'their danger.likely then to see the reactionrefer to as schizophrenic. It is imto recognize that such a disturbnot an evil thing but a desperateto correct a way of life which isto destruction.


7/9

lowing his readiness to give his life forhis family, it came to him that he wascalled upon to save the world from itssins. He saw himself lying in the grave"just like Jesus did." It seemed to himthat he had lived for two thousand years.Sometimes he had been born rich andsometimes poor. Here is a set of ideaswhich occur in case after case. Out of our75 cases, ideas of cosmic catastrophe ap-pear in 43, of cosmic identification in 42,of rebirth or previous incarnation in 14,of prophetic mission in 16. These ideasand their significance I have dealt withelsewhere.8 What claims our attentionhere is the fact that this period is not onlycharacterized by elation, exaltation, anda great profusion of new ideas but is alsomarked by bewilderment and perplexity,with the central problem pertainingusually to the patient's own role. Oscar0. was thus puzzled as to who he wasand what he was to do. He thought hewas going to have to preach. When, how-ever, the voice said to him, "You was go-ing right the way you wasI don't needyou to preach," he was able then to getwell.As in mystical experiences generally,the mind is stirred to its profoundestlevels. There is great enlargement of thefield within which intuition is valid,9 andthe critical faculties are in abeyance. Theyare however by no means absent. Onesees it in the overwhelming perplexitywhich is so often present. In many in-stances the patient is, sure of only onethingthat things are not what they seemto be. He seeks communications fromabove not merely in the ideas which comeinto his head but also in all sorts of trivialhappenings. Here are some examples:H.D. thought some strange struggle was go-ing on and that it was his duty to fathom it.He had to find the hidden meaning of things.The food thus had symbolic significance. The

8 Reference footnote 1. See also Storch, Alfred,Primitive Archaic Thought in Schizophrenia; Wash-ington, Nervous and Mental Disease Publishing Co.,1924.9 Delacroix, Henri, Etudes d'Histoire et de Psy-chologie du Mysticisme; Paris, Felix Alcan, 1908;p. 376.

.doctors' calls, but it came'to him that etime a > bell sounded, one of his friendsbeing shot.R.W. saw something strange in everytthat happened and ominous signs in thetrivial affairs. If another patient put his hto his face, he was conveying some sorwarning. To touch a steam pipe waspecially alarming. He was extremelyservant of the feet.C.T. attached symbolic significance to therangement of the furniture, to incidentalmarks, to snatches of song, to selectionsthe radio, and so on. A crow flying overball field indicated a somber future forA bunch of syringas on the ward were orablossoms and meant that he was going tmarried.C.C. became much disturbed after attenthe religious services at the hospital.sermon had been about the five loavestwo little fishes. He interpreted this to rto himself and his wife and their five child

vR.M. was especially concerned with colorssounds. Yellow meant cowardice, blue trfulness, red blood, black sorrow, purple deThe sight of a girl holding a banana signithat she, the patient, was not a good woShe felt herself influenced by everyone onward and did not know which way to gSimilar perplexity was shown in 2our cases. The proportion would hbeen much higher if there had beeninformation regarding the period of onIn subsequent stages the patientbuild up a new system of beliefs centerin some new concept of his role in lifelike Oscar O., he may conclude that hegoing right the way he was. In such cthe perplexity gives place to some degof self-assurance.

SCHIZOPHRENIC THINKING AS A CREATIPROCESS

Professor Eliot Dole Hutchinsonset forth in a series of articles certain cceptions regarding the process ofsightful" thinking in the fields of scieand art and religion from which I hborrowed some of the categories used


8/9

the facts. They belittle others and mag-nify themselves. They blame others fortheir failures or find an alibi in the formof physical incapacitation. They resort toother face-saving devices. Such personsdo not usually go to pieces, but the reac-tion is a malignant one. They are notlikely to arrive at any satisfactory solu-tion. Here again, however, there maycome a time when the sufferer is awak-ened to his peril and a schizophrenic re-action develops which sometimes succeedsin breaking up the malignant formation.In the hebephrenic type there is the ac-tual disintegration of the personality fromwhich the paranoic is seeking to save him-self. This may develop insidiously, con-sequent upon a withdrawal'reaction, or itmay follow some desperate attempt at re-organization which fails. It is in thisgroup that the leveled and inappropriateaffect and the disjointed speech are foundcharacteristics which are sometimesmistakenly regarded as typical of the en-tire "dementia praeeox" group.11 Fewhebephrenics, however, do not have pe-riods in which they become aware oftheir unhappy state and struggle desper-ately to escape from the toils in whichthey are enmeshed.

Under this interpretation the term cata-tonic is the label which is usually givento those who are engaged in desperatestruggle, those who are stirred to thebottommost depths of their mental lifeand in whom the malignant reactionshave not become established. It is to benoted that of the cases under considera-tion which had not been selected fromthe chronic group 53 percent have maderecoveries, 16 percent have had recurrentepisodes, 13 percent have developed para-noid formations, 9 percent have gonehebephrenic, and 9 percent died beforethe outcome was fully clarified. Whileour statistical base is slender, thesefigures suggest that the schizophrenic re-action tends either to make or break the

"Boisen, The Form and Content of SchizophrenicThinking, reference footnote 1.

. RELIGIOUS EXPERIENCEOscar O. states that he "never didmuch in religion." Neither he norwife went to church, and he consihimself a free-thinker in matters religDuring his psychosis, however, reliwas for him an all-absorbing subject,he thought he was going to havpreach. Out of our 75 patients, 54themselves in direct contact with

superhuman. More than half of thegaged in earnest prayer and Bible-ing. Twenty-six were overwhelmedremorse for past mistakes and sins.may say that all of them, during the aphase of the disturbance, were grapwith the central problems of theologyphilosophy as with matters of lifedeath.It is to be borne in mind that a nuof men of unquestioned religious g

have passed through schizophrenicsodes in the process of finding themseepisodes during which they receivedelations from above in accordancethe process which we have beensidering and gave expression to the cacteristic schizophrenic ideation.Whether the outcome- of a speschizophrenic reaction is destructivconstructive depends chiefly uponhonesty and sincerity with which thetient faces his difficulties, upon theance of assets and liabilities in his cacter and in his life situation, and uthe amount of social support whichreceives. There have been times wheactions which were clearly schizophrwere regarded as evidence of psypower and served as a source of chmatic authority.12 Even today therereligious groups -which value abnormanifestations of a more or less scphrenic nature. Wherever such exences occur within a social matrixfollow accepted social patterns, ther

M Cf . From Max Weber (translated and editeGerth, H. H., and Mills, C. W., New York, OUniversity Press, 1946), pp. 245ff.; also referfootnote 5, Coe, chapter 11.


9/9

THERAPEUTIC IMPLICATIONSIf this interpretation of the schizo-phrenic reaction is correct, it follows thatthe shock treatments and lobotomy are notto be used indiscriminately. Such treat-ments may produce peace of mind, butthey are not likely to contribute to. theconstructive solution of the problem withwhich the schizophrenic patient is grap-

10 Boisen, Economic Distress and Religious Ex-perience, PSYCHIATRY (1939) 2:185-194.

It follows furthermore that thethe psychotherapist requires thata true understanding of the consand destructive forces which areing in the acutely disturbed schizoand that he should assist the consforces by providing the social swhich the patient needs so despWith recovery or remission, the nehelp him to interpret the experiento see it in true perspective.ELGIN, ILLINOIS

Onset in Acute schizophrenia 1947 inicio de esquizofrenía aguda.pdf

Documents

Transcript of Onset in Acute schizophrenia 1947 inicio de esquizofrenía aguda.pdf