The Psychodynamic Process of Illness and Recovery in a Case of Catatonic Schizophrenia

[This extended case presentation of a young man’s progress through a severe psychotic episode is remarkable for the patient’s ability to offer a good account of their state of mind during episode’s most severe phases.]

Andras Angyal  (1950) Psychiatry, 13:149-165.

The assumption has variously been made that a mental illness may represent an attempt at a problem solution—an attempt that   too often miscarries but in some instances actually succeeds. Although this is a widely held opinion, it is only rarely that one has the opportunity to clearly view the dynamic process whereby a patient grapples with and resolves his problem in the experience of a psychosis. The following history of the illness and recovery of a young man who has gone through a rather extended episode of catatonic schizophrenia offers an unusual opportunity to observe in detail the workings of constructive impulses and to study the steps in the dynamic process which gradually led to his recovery and to the resolution of his problem. The patient—whom I shall call B—after recovering from his illness, was able to recall vividly and describe accurately his psychotic experiences. His account gives us a most graphic picture of the way the catatonic behavior and  experience appear from the inside.

First, I shall give a brief outline of B’s family background and of his prepsychotic history in order to specify the immediate problem with which he struggled in his psychosis. This will be followed by a detailed history of illness, based on B’s own account, which will form the main body of my data. On the basis of these data I shall attempt to describe the dynamic process that was involved in this catatonic mode of problem solution and to trace step by step the constructive efforts toward recovery.

FAMILY BACKGROUND

The patient, a 22-year-old electrician, was the fifth of eleven siblings. The father was described by outsiders as an unstable person who was easily upset and had a violent temper. He was considered as being inferior to his wife in regard to education, intelligence, and personality.  He was a mechanic by trade, but his income was usually too low to support adequately the large family. For years they lived in a shack without electricity or running water and at times they did not have enough to eat.

B described his father as an extremely selfish and immature person. One of his methods of getting attention was to declare himself sick, go to bed, and have the rest of the family take care of him. For a period of four years he claimed that he had a stomach ailment.  Although the physicians did not find any confirming evidence, he put himself on a special and—to say the least—peculiar diet. For instance. “He would have to have his steak when for the rest of the family there was only potato and maybe a little hamburger. ” Also, he always managed to have one or two new suits, while the children went ill-clad.

B often wished to have an older person in whom he could confide and whom he could ask for advice, but asking his father’s advice “would have been no better than seeking advice from a 2-year-old child.” Although the patient sees clearly his father’s faults, he believes that he is . “fundamentally not a bad sort but only a weak person.” On the whole the patient’s conscious attitude toward his father is one of understanding tolerance.

The father’s relation to his wife is significantly illustrated by the following incident that occurred when B was about 14 years old. B was sleeping in the room adjacent to the parents’ bedroom when he was awakened by his father shouting.  He was accusing the mother, who was pregnant at the time with her eleventh child, of being unfaithful and pregnant by another man. Soon these accusations came into the open because the father did not refrain from repeating them in front of the children. His repeated outbreaks of  jealousy upset the whole family, particularly when he was threatening to kill the man with whom he thought his wife was having relations. Someone in the family also discovered that the father was hiding a razor in his bed. The children never gave credence to the father’s accusations. The mother was desperate and helpless in the face of this situation and asked her children for counsel as to what to do. She told the children that the father also made similar accusations during her previous  pregnancies. It was only upon the persuasion of the children that she remained in the home and tried to put up as well as she could with the scenes created by her husband.

B was said to have been deeply attached to his mother. She was a schoolteacher before she married and was a cultured and refined person. She is described by everybody as a “fine woman,” devoted to her home and children. She was a quiet, hard-working, socially-minded, conscientious person and a devoted church member. Just before her eleventh child was due to be born, she had an eclamptic seizure. The child was removed by a Caesarean section, but the mother did not survive the operation. This  child was adopted by another family.

Of the eleven siblings, three of the brothers are older than the patient. They left home soon after they could earn a living. The circumstances under which they left are worth mentioning. The brother next to the oldest one was the first to leave. He was earning at that time  $16 a week from which he paid $10 for his room and board at home. At one time this brother got sick and was unable to work for a period of six weeks.  When he recovered, the father demanded that he pay the usual amount for the period of illness, arguing that although he did not earn money, he was maintained by the family during his illness. The brother, who had a quick temper, left home and never returned.

The other two older brothers of the patient left together. Their leaving was precipitated by the following incident: They decided to send the youngest sister, because of her health, to a summer camp, using their savings for this purpose, but they told the father that the church was financing her vacation. They asked the father to buy her a suitcase for the trip.  When he refused, the brothers admitted that they were giving the money for the vacation and told him that he could at least contribute the expenditure for the suitcase. The argument that ensued ended with the two brothers leaving home.

The patient felt very bad about the departure of his brothers, particularly the oldest one for whom he had great respect  and to whom he was very much attached.  The patient for a long time tried to reconcile the father and his brothers, with the result that the brothers became less confiding and somewhat restrained with B since they were afraid that B might tell the father more about them than they wished him to know.  On the other hand the father resented it when B tried to present the brothers’ side of the story. At the time that B came to the Worcester State Hospital, he was 22 years old,  and the three older brothers were at that time 27, 25, and 23 years old, respectively.

He had a sister of 21, a poorly adjusted and drifting sort of person; a brother of 10, in the Army at that time; another brother of 17, who was just finishing high school; and four younger sisters of 15, 14, 12 and 7—the last being the child who was adopted by another family. All of  the siblings, with the exception of the  oldest sister, are said to be well adjusted.

After the patient’s mother died, a middle-aged widow was taken into the home as a housekeeper. She was a kind  person and was well liked by all the children, who accepted her practically as a second mother. She did an excellent job of keeping the home together. The father’s attitude toward the housekeeper was in many respects a repetition of his  previous relationship with his wife. On three separate occasions he was about to marry the housekeeper, but at the last moment he always changed his mind. There was much quarrelling between her  and the father, and every once in a while she would pack up and leave, but she would soon return. The children definitely sided with her and felt that the  father was treating her unfairly.

Very little is known about B’s early development. He is described as having been a likable, sensitive, quiet child. He seemed to be greatly disturbed by any noise, quarrel, or confusion, and on such occasions he withdrew and stayed by  himself.  He was always very neat about his person and whatever personal possessions he had. He had a great love for nice things and “culture.”

In grammar school and high school his work was somewhat above average, and he was well liked by his teachers and schoolmates. After finishing high school, he went to work for the local public utility company. There they thought very highly of him as an industrious and intelligent employee and considered him an unusually fine person.

His social life, as well as the social life  of his brothers, centered around the neighborhood Baptist Church. He sang in the  choir and spent several summer vacations at the church’s summer camp. In the  church he became acquainted with the music director, K, to whom I will frequently refer in describing B’s illness.   K was a bachelor in his middle forties and a person of some means. He was a somewhat strange person and no one seemed to know much about him or his background.  He was widely read, had. a great deal of knowledge of literature, music, and art. He took great interest in the boys who belonged to the  church, teaching them and also helping  the poorer boys financially. He always  had some special favorite among the boys.

About two years previous to the onset  of B’s illness, B expressed a desire to have  his voice trained, and K offered to give  him free singing lessons. Very soon they  became inseparable friends. Besides the singing lessons, K directed B’s reading. They discussed books together, visited  historical places in the vicinity and  went to  concerts and the theater.

The friendship with K had an extraordinary significance for B. He now had  access, under expert guidance, to all the  things for which he had always yearned:  art, culture, refinement. Furthermore he  now had an older friend in whom he could confide, to whom he could go for advice  — a role for which his own father was completely unsuited.

One might suspect that this close friendship between young B and a man more  than twice his own age might be on a  homosexual basis.  B, however, was not conscious, in retrospect, of any such feelings in himself, and there was nothing  “improper” in the behavior of K toward  the patient. K’s feeling about the situation may have been, however, a very different matter.  I had opportunity to interview K and to get a personal impression of him. It seems fairly certain to me that in K’s attachment to the boys from the church there was a large element of homosexuality. There is, however, no evidence that he had ever made any amorous approaches toward the boys. Whatever homosexual tendencies K may have, he has also a great deal of control and a great deal of sublimation in artistic, religious, and educational pursuits. He impresses one as an emotionally isolated, lonely  person who has derived from his association with the boys a great deal of  substitute satisfaction for his lack of close  human relationships. It was rather obvious that he had a very deep emotional  attachment of some sort toward B.  One obvious disadvantage of this relationship  for B was that K rather monopolized him,  which somewhat restricted B’s associations with his contemporaries.

Until the time when this friendship with K developed,  B’s relations with girls  were very much like those of other boys  of his age. At about the same time that  he and K became close friends, B met a  girl, D, at the church’s summer camp, and  they fell in love with each other and considered themselves engaged. Their actual contacts were limited because the girl  lived in another city at a considerable  distance; but obviously they had a very genuine devotion for each other.  K  strongly disapproved of this relation, but on this point B was firm in following his  own feelings. When K spoke with me on this subject, there was no doubt in my mind that he was very jealous, although  he rationalized his attitude by saying  that he wished that B would find a suitable girl to marry, but that this particular  girl was “crude, loud, and not worthy of such a fine young man as B.”

In December 1942, when B was 21 years old. he was inducted into the Army. He was not enthusiastic about the prospect of army life. He regretted also that he had  to interrupt his studies in electrical engineering, which he took in the evening in order to improve his occupational standing. But once he was  inducted, he took it in a rather matter of fact manner.  He was, however, still very unhappy about the situation in the home. The father’s violent outbursts of temper and his childish unreasonableness kept the family in a constant state of upheaval.  For B, who was a very sensitive person, this atmosphere of continuous emotional turmoil was almost unbearable. Just before he left for the service, he told the housekeeper in confidence of his despair about this hopelessly unhappy family situation. He told her that he did not want to cause any painful discussions at that time, but he felt that he should not return home after the war was over.

B entered military service on December 28, 1942. After he completed his basic training, he was transferred to a military camp in Florida for specialized, training in radar operation for which he was selected on the basis of his previous occupational experience. His illness began very soon after his transfer and was first noted on February 20, 1943, about two months after his induction. He was then admitted to the neuropsychiatric ward of the station  hospital for observation. There he showed bizarre behavior and appeared deluded and hallucinated; later be became resistive and stuporous, and refused to take any food. After two months’ stay in the military hospital he showed no signs of improvement and was discharged from the Army and. sent home. On his arrival at home on May 3, 1943, his condition was such that he had to be hospitalized immediately. In the hospital he showed typical signs of a catatonic stupor with waxy flexibility, mutism, refusal of food, incontinence.  Toward the end of 1943 he began to show signs of improvement. On February 2, 1944, B was transferred to the Worcester State Hospital for a special study.[1] By that time he was free of any overt psychotic symptoms; but in view of  his recent illness a further period of observation was indicated. He remained in  the Worcester State Hospital until February 27, 1944.

My first contact with B was on February 2, 1944,  at the Worcester State Hospital, where he had been transferred from  another state hospital. His illness had  begun almost exactly a year before this  date. The patient remained for 23 days  at Worcester before he was released as  recovered. The main part of the material  of this paper was obtained in interviews  with the patient during this latter period  of time. He was seen for from one  to  two hours daily, five times  a week—a total of from 20 to 25 hours.  At the first interview I was impressed by the patient’s ability to give an unusually accurate and detailed account of his morbid experiences.  His cooperation n reviewing with me the history of his illness was readily enlisted.  During the interviews that followed, rather accurate notes were taken. Whenever possible, the patient’s own words will be used in describing the history of his illness.

THE HISTORY OF ILLNESS

First Phase: Discovery of a New World

B’s unusual experiences began without warning or preliminaries three days after his admission to the station hospital at the military camp. There was no noticeable  gradual development, but a fully developed delusional system made its appearance at one stroke. He woke up with the conviction – which he “knew for a fact” -that he was selected to serve as a member of the FBI. This was happening through the agency of K, the patient’s best friend.  B’s idea was that the FBI was employing a number of agents, distributed throughout the armed forces, who were posing as ordinary enlisted men and had special secret assignments.  K was  the “headman” in this secret organization.  It did not seem strange at all to B that during all the years he knew K he had “no inkling of the man’s true identity” because he assumed that K had to work in disguise to discharge efficiently the duties of his office.

B was very proud of his special assignment, which gave him a feeling of great importance.  He kept his thoughts and  feelings to  himself and went about his soldierly duties in the usual way. In retrospect he is convinced that he behaved so casually that no one could have suspected what was going on in him.

Two sets of experiences occupied him during this period: (1) he felt that he was being  “tested” as to his ability as an FBI agent and (2) he knew that a message, a secret order, was to be conveyed to him.  B noticed a “dopey feeling” whenever he smoked a cigarette or ate a piece of candy, and he assumed that the candy and cigarettes were “doped with morphine.” This was done to test whether he would give away the secret, or whether he was strong enough to keep it concealed even under the influence of a narcotic.

“The message” was being transmitted to him in a very cautious and circuitous way. The text of the message was divided among a number of FBI agents who posed as soldiers in the camp. He had to listen carefully to what was spoken around him —taking a phrase from the conversation of one man, a word from the speech of another man, and so on, and then fitting the fragments together into a meaningful text that was intended to be conveyed to him.

Everything began to take on meaning and significance and to be related to this idea. For instance, on one occasion he met a man on the street who asked him for a certain address. The patient began to explain: “Go two blocks and then turn to the right—” The stranger interrupted him: “You mean at the corner where the ice cream stand is?” Then the patient thought: “This man knows his way around here better than I do.” And suddenly he knew that their meeting was not accidental, and he “remembered” that he came to a secret appointment with this man. He took a word or two from what this man said to fit into his jigsaw puzzle —one more step in “decoding the text.”  By the end of the second day he understood clearly his “first assignment.” In the camp there was a special section surrounded by barbed wire, about which there was—in reality—a special secrecy. He was to enter this section at night and to see the officer in charge. He worked out his plan carefully. At night he went to the place, challenged the guard, and managed to cause enough disturbance so that he was brought before the officer in charge for questioning. He gave a more or less plausible explanation. The officer apparently thought that B was either intoxicated or upset about something and told him to go back to the barracks to sleep. He went back to the barracks and “fell asleep with the glorious feeling of having successfully accomplished the first assignment.”

Next day, listening intently to “snatches of conversation,” he thought he deciphered his final orders: He was to change his identity, assume a new name, and go to his home town to report to K for further instructions. He took everything  “that would identify him—his dog tag, wrist watch, a gold ring with his initials on it, his driver’s license, Social Security card, and all other documents he had – and  threw them into a furnace. He kept only his identification card. While he was searching his pockets for objects that might identify him, he came upon a comb, and this gave him the idea to take on the fictitious name of Withcomb. He erased his name on the identification card and forged the fictitious name Glen Withcomb on it.

After he accomplished all this, he went back to the barracks to retire. As he entered the barracks he suddenly remembered a scene that had actually occurred a few nights before. At that time one of the soldiers, who was probably somewhat intoxicated, came into the barracks late and as a practical joke turned on all the lights, thereby waking up the other soldiers and making quite a commotion in the barracks. As B remembered this, he knew at once with certainty that he was to re-enact the scene. Thus he turned on. the lights, waking his fellow soldiers, who began to shout at him, until the sergeant in charge interceded and ordered him to bed.

The sergeant was probably irritated by the fact that this joke had been played twice within a few days. and the next morning he reported the incident to the officer. When B was brought before the officer, he insisted that his name was Glen Withcomb. He must have acted very convincingly. The sergeant finally stated with hesitation that he was rather certain that he knew this soldier by another name. Finally it was decided that two soldiers who were close chums of B were to be called in.  B had believed that these two soldiers were also secret agents, although he had never spoken with them about the matter. He was “thunderstruck” when these soldiers identified him by his true name and “could not understand how these men could let [him] down.” At this point B declared that he was not at liberty to make any further statements and requested that the officer get in touch with K who would clear up the situation..

B was then admitted to the neuropsychiatric ward of the station hospital. In the hospital he was neither concerned nor discouraged about his condition; he considered it as part of the secret plan and believed that his confinement in the hospital was just another test he had to pass.

In the hospital he continued to listen to conversations around him for secret hints and orders. He was so intent on the secret meanings that he entirely disregarded the obvious content of what was told to him. B states that not once did it occur to him to doubt his experiences and interpretations, and that no amount of persuasion would have been of any use, because whatever was said to him by the physicians and employees he thought was “only a camouflage for what they really meant to convey.”

Soon after admission to the hospital the patient began to experience auditory hallucinations. He was neither frightened nor astonished by “the voices,” but rather considered this new experience as a “great revelation.” He thought that the ability for hearing voices of people who were not present was a natural human ability and that up to this time he had “missed something in life”; these things were happening all the time but up to now he had been “ignorant of them.” In retrospect, B compared this experience with some dreams in which one believes he has discovered how to fly and is astonished how simple it is and wonders why he did not know it before.

Besides the actual auditory hallucinations, he had the experience of “thought transmission.” He thought that the human brain worked like a radio and was able to transmit thoughts at great distances. The patient claims that such experiences were usually preceded by a sharp pain in his head. This was a signal  for him that somebody was trying to contact him and transmit thoughts to him. He twisted his head and body in order to “tune in,” until he could clearly perceive the thoughts. The messages which he received were either in the nature of encouragement – “You are doing all right, keep it up”—or were parts of a secret  order.  B also felt that he was able to  transmit thoughts and could keep up a  conversation with his distant partners.

B’s interpretations of the happenings  in his surroundings assumed such proportions that practically nothing retained its old conventional meaning. He felt that he was living in a new world, the  meaning of which he had just begun to  discover. Very soon a new feature was added to the symptomatology:  not only  what was spoken and what was happening in the environment began to assume  new meaning, but also his own actions.   Every little movement he made assumed  an almost cosmic significance. He had the  feeling that even lifting a finger or taking a step would have incalculable important consequences. [The reader may recall the concluding scene of the film Psycho, in which Norman Bates immobilizes himself to not convey anything to those around him.] The idea of the  tremendous significance of every little movement, coupled with the idea of living in a new world, the meaning of which was about to be disclosed to him, soon  froze B into an almost complete inactivity.   He would now stand motionless in the same spot for hours and would move only when he felt that he received secret orders to do so. He now habitually stood  in a stereotyped posture with his head  bent forward, watching his own feet.  The feet seemed to him to have some “vital significance,” and he did not dare to take his eyes off them. Due to this continuous uncomfortable posture, he had  great pain in the muscles of his neck but he did not dare to straighten his neck.  Sometimes in the evening, when he was put to bed, he “stealthily” stretched his neck. for a moment, but he felt very guilty about it as if he had done something wrong.

During this period he did not take any food in spite of being very hungry, and he had to be fed artificially. The reason for not eating was partly that he would do only what he thought he was specifically “instructed” to do: since he had no orders to eat, he would not do it. In addition he had the idea that there was something wrong about eating, particularly eating candy and smoking cigarettes.  He recalls many times when attempts  were made to force him to eat. On one  occasion one of the attendants forced a  piece of chocolate between his lips. He had neither the initiative to eat it nor to  spit it out—he had no secret orders for  either—and he just let it stay between  his lips for maybe a half hour until it  dropped out.

The urge for elimination was not strong  enough to motivate him to lake care of  his needs. Because he did not receive any  specific secret instructions, he retained  the contents of his bowels and bladder.   He had to be relieved by enemas, and  when his bladder became so distended that he could not retain its contents any  longer, he became untidy.

The patient might have appeared entirely out of contact with his environment to an outside observer, but actually he was “all eyes and ears,” and nothing that  could be interpreted as a secret message  escaped his attention. He was very keen  in picking out minor items in the environment and interpreting them as signals. For instance, another patient was  standing with arms crossed in front of  his chest and with an outstretched index  finger. This meant that he was secretly pointing out the direction which the patient should follow, and he immediately  crossed the room in the direction in which  the other person’s finger was accidentally pointing. Another person was sitting with his legs crossed and his toes pointed in a given direction. For the patient, this was an order to walk in that direction, and he immediately acted upon it.. There was another patient who in a manneristic way continuously scratched his head and thus inadvertently made a movement like thumbing. The patient took this as a secret instruction as to which direction to go.

B gradually connected these isolated observations and interpretations into a coherent story. He felt that on the hospital ward the war was being fought in miniature.  One of the patients, who had a peculiarly shaped nose and closely cut hair, reminded him of Stalin; and he took this person for a representative of the Russian State. Another person he misidentified as a German emissary. Certain political roles were ascribed to many other persons on the ward. The patient had the notion of some sort of a parallelism between a kind of microcosmos and a macrocosmos, and he believed that the symbolic fighting of the war in the hospital was actually repeated on the real battlefields. It never occurred to him actually to assault any of the “enemies.” It was sufficient to “cross the other person’s path” or to make an “encircling movement.” The secret signs and orders were numerous, and he had a peculiar facility for interpreting everything according to his prevalent ideas. The placement of objects had particular significance. Thus, for example, on one occasion an officer came in and put his cap, on which there were some insignia, across a book. To the patient this meant, “You crossed your signals,” which in military language means that one has made a mistake.

There followed a short period, maybe a week, during which he became somewhat more spontaneous. This period started with the idea that certain foods might help to develop his ability to perceive and transmit thoughts at a distance. Consequently he began to eat on his own initiative, and he also became slightly more free in his other behavior.

During this period it happened that on one occasion when he flushed the toilet in the washroom, he heard an airplane flying overhead. This gave him the idea that the water system in the camp was a communication system and that the airplane took off because he gave a signal. For about two days he spent most of his time in the washroom pushing the flush buttons and by this means “sending off airplanes.” Airplanes went over the camp so frequently that he was never disappointed in his expectation; a minute or two after he pushed the button, an airplane would usually be heard.

In the letters he received during this  time, he was looking for secret communications. He received several letters from  K which he interpreted in a peculiar way.   K had the habit of crossing his fs above the vertical stroke which gave the impression that the word in the line above was  underlined. Then again, some words were written in darker strokes where the pen  had been freshly dipped into the ink. The patient was so convinced that the rest  of the letter was only camouflage that he never took pains to read the letter as a  whole, but read only those words which  he thought were specifically marked for him. At Easter time he received a card  from his brother, with the picture of a  rabbit that had large popping eyes and  big ears. This was interpreted as a message: “You are doing fine work, you are  all eyes and ears”—as he actually was.  The patient states that not for a moment did it occur to him to consider this card  as being simply an Easter greeting.

The period of somewhat greater spontaneity was only brief. At the end of this period, he realized that he had been  “tricked” by the idea that food was helping to develop his “telepathic power.” He again thought that there was something wrong about eating; as a result he stopped taking nourishment and relapsed into a state where no spontaneous activity was possible for him. He continued in this condition until the end of his stay in the station hospital. Altogether he spent somewhat over two months in the military hospital and was then discharged from the Army and sent back to his home accompanied by a medical officer and two aides.

During the journey he remained mute, refused food. and sat in one corner of the compartment in a catatonic posture, his head turned to the side.  But inside he was happy. He was now going to meet K. He had successfully completed his assignments so far; had passed the “tests” to which he had been subjected, and was to receive his rank and his final orders from. K.  While he was sitting there in an apparently pitiful state, he was actually greatly enjoying the journey, “taking in all the scenery.”

Second Phase: In the Clutches of the Enemy

When B arrived home, the whole world  changed for him all at once. He knew now with certainty that for the last months he had  lived “in a fool’s paradise”  and that he was “cheated and deceived.”  He felt that he had been tricked by K,  who was no FBI chief but a powerful  enemy, an agent of the Japanese embassy.   The patient “knew” now that K was holding him in bondage, and that his family  had to make every sacrifice to keep him  alive. In order to pacify K, the family had  to give him all that they possessed, but  K wanted more and more. The patient believed that while he was away K had  gradually taken over everything that the  family had—the house, the money, and  even the furniture.

Outwardly, B was in a catatonic stupor.   He did not speak or move spontaneously, so that a few hours after his arrival at home, he had to be transported to a hospital for the care of the mentally ill. He remembers that at first he was entirely motionless, but that he knew what was going on around him, even if he interpreted many of the events wrongly. He was sensitive to pain; and he recalls, for instance, how unpleasant it was when the physician scratched his sole in order to test the Babinski reflex, but in spite of the disagreeable sensation he did not move. He felt hungry, felt the urge for elimination, but none of these needs were sufficient to motivate him to action. When the examining physician placed his arm in an uncomfortable position, he did not have enough initiative to change the position of his arm. .The patient’s emotional attitude reached a point where he “just did not care any more what happened.” It is remarkable, however, that during this time, as well as during the entire period of illness, the patient had vaguely, “in the back of his mind, the feeling that everything would turn out all right in the end.”

His misinterpretations continued unabated. For instance, when he arrived at the hospital, the attendant was hurriedly changing the patient’s clothes and put his shorts on backwards. The patient interpreted this to mean: “We are retreating”—that is, our armies are retreating. On another occasion, an orderly who was shaving him applied the soap with the strokes towards the point of the chin, shaved that part of his face first, leaving the mustache till last. The patient interpreted this to mean that a friend was around there who was trying to help him, and this unknown friend was a person with a long chin and with a mustache.

For the next two months the central theme of B’s preoccupation was the thought that his family was gradually impoverished, for they had to give more and more to K in whose bondage B felt himself to be. On one occasion his brother came to the hospital to visit him, and B noticed that the brother had a flashlight— which he used in his work—in his back pocket. B interpreted this to mean that. his brother had already given everything away to K, and that he was now taking K his last possession, a flashlight.  To K, who frequently visited the patient in the hospital, B gave no outward sign of his feelings.

When the family visited him in the hospital and brought him fruit and other edibles, he did not dare to touch them because he thought that, after everything that the family possessed was consumed, the members of his family would themselves have to go into K’s bondage in order to keep the patient alive.

On one occasion, about two months after his entrance into the hospital, an attendant asked B how he was. He felt annoyed and answered, “Let me alone.” These were the first words which he had  spoken in that hospital. The attendant, wanting to take advantage of the opportunity, told B that his relatives had left some oranges and cigarettes for him and offered to bring them to him.  B decided that he would go on a “last spree,” and he accepted the food and cigarettes. He ate and smoked but he felt horribly guilty. He thought that the orange and the cigarette were the very last possessions of the family; and that when he had consumed them, the life of his youngest sister would then have to be sacrificed: she – and after her the rest of the family  — would soon have to go into the bondage of K, whose greed was insatiable.

B felt that he had come to the end of  his rope. He made up his mind to relieve the family of the burden of keeping him alive and decided to take his own life. There was a glass door in the hall, and he resolved to thrust his head through the glass door and then, twisting his neck around, to cut the blood vessels of his  neck with the jagged edges of glass. He actually thrust his head through the glass door but at that moment the idea flashed through his mind that neither he nor the family would be helped by this action, so he did not carry his plan to completion. He got away with a few minor scratches.

Third Phase: Escape Through Magic

The suicidal attempt marked the beginning of another phase in B’s illness. Two simultaneous developments characterized  this phase: B began to exhibit a slight degree of spontaneity, and he discovered a “method” to extricate himself from his fancied predicament.

Since the spontaneous activities of B were still only an outgrowth of a distorted phantasy world, they were extremely grotesque. Some examples may illustrate this:

On one occasion the father, who was visiting B in the hospital, said to him: “You certainly would get well, son, if you would only learn how to eat.”  B took this statement to mean that he had to learn to eat in some special new way.  He began  to watch for signs that would indicate how to eat in the right way. He finally discovered a system which allowed him to eat at least a small amount.  He observed how the plates, forks, knives, and spoons were arranged, and in that arrangement he thought he detected signals and signs for a permissible mode of eating. Thus, if the fork was pointing towards the soup, he could have all of the soup that he could take with the fork; so he ate the soup with the fork, naturally getting only the solid parts. If the knife pointed toward nothing in particular, that meant that he could have everything except that food which would require the use of the knife. If the spoon pointed toward a glass of water, he would take water with the spoon—and so on. He carefully selected the place in the dining room that would.  allow him to take a reasonable amount of nourishment; but since he was slow in doing so, the other patients would usually occupy all the “good places.”

Although B previously had not spoken at all, he now began to respond with “yes” or “no” “to his visitors’ questions and they considered this as some improvement.  Actually B’s answers were not at all answers to the questions put to him; his utterings were in response to some minor features in the environment, quite independent of the questions put to him. Here are some examples: The button on one of his shirt sleeves was sewed on in the usual way, namely, the thread forming two parallel lines, while on the other sleeve the thread crossed. He interpreted this to mean “plus” and “minus,” or “negative” and “positive.” If someone asked him a question and the interrogator’s face was turned more to the side on which the button on the shirt formed the plus sign, he answered, “yes.” If the face was turned towards the minus side, he answered, “no.”‘ One day when his brother visited him, he brought with him a newspaper on which B saw printed “Doctor Crane.” He interpreted the D as signifying “debit,” and the C “credit.” Thus, whenever his brother asked him a question and his face was turned more toward the D, he answered, “no”—if more toward the C, he answered, “yes.”

More characteristic than these minor spontaneous activities and utterances at this stage of the illness was the discovery by B of a peculiar technique—a magic method of extricating himself from the clutches of K. This development began with the notion that a person could exist only if some material thing represented him in the world.  Possession and personal existence seemed almost equivalent.  Living consisted essentially of “swapping” one possession for another and trying to  do it in the most advantageous way. If B was sitting in a chair, that meant to him that he possessed that chair. Now the idea was to swap the chair for something more valuable, say the table, and then to swap the table, maybe for the whole room. It appeared to B that everybody was engaged continually in this business of  “swapping.” The method of taking possession of a new object consisted in moving over to it or looking at it or just focusing one’s attention to it. There. was a competition between people. The one who was quickest got possession of the most desirable objects.

When B detected the swapping as the fundamental meaning of life, he accepted it in exactly the same way as he had previously accepted his hallucinations:  The world had always been that way, but he had not known about it.  He felt that other  people had much more skill than he had— that they could move around freely, gracefully, and at the same time swap more advantageously. For the patient, it was an extremely cumbersome matter to move about and at the same time calculate his steps with respect to an advantageous exchange of holdings.

Around this time B noticed that noises in the environment—such as the rustling of clothes, the squeaking of the floor underfoot—began to form words and sentences. These experiences replaced the more common form of hallucinations that B had previously heard. He sometimes would listen half the night for the noises which his two roommates made when turning in their sleep. He understood. these noises as a conversation between the roommates who were planning the strategy and discussing the tricks that they would use in the next day’s swapping. B would keep awake and listen intently in order to gain an advantage for the next day’s competition through the information which he thus obtained.

B, in his phantasy, was gradually acquiring skill in the technique of swapping, and he began to “accumulate property.” It was not long before he believed that he acquired possession of the whole building, of the surrounding grounds, and the like. In fact he believed himself to be a king, and he thought that the other patients were serving him. Now the tables were turned: The family regained all that they had lost and more.  He fancied them living in a luxurious palace.  He deprived K, whom he hated intensely, of all his possessions. One day he decided to seek final revenge: By making the furniture squeak, he ordered K to be executed. Another patient made some noise which B perceived to be a question as to whether he, B, wanted to be present at the execution.. B answered, “No, I don’t want to see him any more.” He was disappointed and greatly enraged when, on the next visiting day, K appeared again.

During the period when he entertained grandiose ideas, some of the other symptoms began to recede, and his behavior became more spontaneous. One also gains the impression that during this phase of grandiosity there was some playfulness in B’s attitude toward his symptoms. The symptomatology was now characterized by some shallowness, and one no longer had the impression of a strong internal struggle that was so characteristic in the previous phases of the illness.

Fourth Phase: The Dawning of Insight

During all this time K had no inkling of what was going on in B’s mind and visited him in the hospital regularly every week end. The patient did not show overtly his feelings towards K, but he hated to be with him, suspecting that he was “up to some trick,” trying to swap the patient’s valuable possessions for some worthless thing. K used to bring the patient small presents and read to him aloud, and later he took him for walks around a lake on the hospital grounds. On one occasion during such a walk, B had a peculiar experience: The objects of the surroundings appeared to be far away —a short section of the road looked as if it stretched for miles. Then again, everything looked extremely small—the lake “did not seem any larger than the top of this desk.”  He felt weak and had to sit down on a bench. And now, for the first time during his illness, he realized that he was sick. Until this time he misinterpreted his hospital surroundings as a place where he was being tested, or distorted the world about him in some other delusional manner, and—in spite of the presence of nurses and doctors, in spite of the medical examinations and other features of the hospital life—it never occurred to him that he might be sick.

Now his concern with his health largely displaced his other psychotic preoccupations. He believed that he was suffering from a heart disease because of a feeling of weakness  and of exhaustion in climbing stairs—which was not astonishing in view of his inactivity for many months, his refusal of food and the resulting loss of weight. He worked out for himself an elaborate diet. He stopped drinking coffee and smoking, and avoided any items of food that he thought would affect his heart.

The hypochondriacal preoccupations pushed the patient’s delusion world into the background. He began to associate more freely with other patients, and his general behavior improved considerably. Time began to hang heavy on his hands, and he asked for some light work. He was assigned to the industrial department of  the hospital. Superficially he must have  shown much improvement because at this time ground parole privileges were granted to him.

In the industrial department a foreman  took a special interest in B. On one occasion when he was driving to a nearby town, he took B with him. After the foreman finished his errand, he asked B  whether he would like to buy something.   B said he would like to have a pack of cards for the ward and a pad of paper to  write the scores on. The foreman told B  to go by himself and do the shopping.   B says that the man’s confidence in him  gave him a “tremendous boost.” On an other occasion the foreman took him to  his home for Sunday dinner. When coffee  was served, B was able to overcome his  fear, and he accepted it in order not to offend his host.

By Thanksgiving 1943, about 6 months  after his admission, he was allowed to go home for a day’s visit. He spent the day comfortably, but on returning to the hospital he was afraid that he had overindulged in eating and that his health had become worse. He did not want to get up in the morning, thinking that he was sick. However, when the doctor told him that there was nothing wrong with him and ordered him to get up, he did so and went to work.

The following night he had a remarkable experience. He lay awake in bed almost the whole night, but he did not  feel tired or sleepy. On the contrary, he  was unusually alert, his mind was exceptionally clear, and a feeling of calm and  peace came over him. It dawned on him  that his heart ailment existed only in his  imagination; he saw that in spite of working all day, he was well, and he realized  how unfounded his fears were. He considered the fact that he had passed the Army  medical examination and had had several  medical examinations subsequently, and  that the doctors had never found any ailment. Then all of a sudden he saw quite  clearly that he must have been mentally  ill and that he had lived in a strange world  of phantasy for many months. This experience was like awakening from a dream.   As soon as the insight occurred, he had no  doubt that he had been living in a dream  world, in a phantastic creation of his own  mind. He remembered the “dream” vividly and recounted it to himself in all its details with perfectly clear insight into  the unreality of those weird experiences.   The experience of that night marked the cessation of all psychotic symptoms.

My first contact with B was shortly after this episode—at the time of his transfer to the Worcester State Hospital  for a special study. Twenty-five days  after this he was released from the hospital, and he went to live with an older brother who was married, instead of returning to his father’s home. He obtained employment in his old place of work.  There he made an excellent adjustment and received two promotions during the first year. Though he has maintained friendly relations with K, their contacts became much less frequent and much less absorbing than they had been before.  In  accordance with the regulations of this  State, he received his official discharge a year after the date of his leaving the hospital. As soon as he received his hospital  discharge paper, he married D, as he had  already planned before his illness. About a year after they got married, they had  their first child. At the time of the last check, three years after his recovery, B  was making an excellent adjustment.

DISCUSSION OF THE PSYCHODYNAMIC PROCESS

In order to comprehend the meaning  of B’s psychosis and recovery, one has to visualize the immediate personal situation in which he was entangled at the onset of his illness.[2]He found himself confronted with several interrelated problems which required—sooner or later—some important decisions on his part. He was  caught in a family situation which was  most disturbing to him. The father’s immature, selfish attitude and his frequent violent outbursts of anger kept the whole family in a state of continuous upheaval and uncertainty. For B, who had a very sensitive impressionable nature, this family atmosphere must have been particularly agonizing. B had before him the  examples of his three older brothers, who broke with the father and left home just as soon as they were able to maintain themselves. Yet instead of following his brothers’ example, B remained at home, and against all odds he tried to bring about a reconciliation between the father and the brothers, which only resulted in arousing the father’s resentment and alienating his brothers from himself. B explained his reluctance to make an open break with  the father by his abhorrence of violent scenes. However, his behavior made it obvious that the psychological ties to the family must have been very strong and extremely difficult for him to dissolve.

For the two years preceding the onset  of his illness, B found a temporary escape and a partial compensation for his unhappy home situation in his friendship with K.  The appearance of K in the life  of B must have been of crucial importance. In him, he found a “good father” —  an older friend who could guide him and  advise him, and who opened for him the door to the finer things in life for which he had such an intense yearning. And  still, this friendship with all its gains was  not quite what he really wanted and  needed. He might have unconsciously sensed that this relationship involved  more than he originally bargained for: if  not the danger of a possible homosexual  implication in this attachment to and  affection for each other, then at least the danger of an overdependency on K must  have been disturbingly present in the  background.

His relationship to K posed for him still another dilemma. B was sincerely in love with D, whom he planned to marry some day, but he was faced with the confusing and disturbing fact that his respected and cherished friend violently disapproved of her.

All these conflicting problems awaited solution—some important decisions on B’s part. The interruption of B’s ordinary routine of life through military service did not make the need for solution less pressing, but probably even more so. He knew that after his return from the Army all his problems would have to be faced. The conversation he had with the housekeeper before leaving for the Army suggests his perceiving that the decision could no longer be postponed; it also suggests that emotionally he was not ready to make the decision.

Taking a bird’s-eye view of the whole course of illness, and disregarding for the moment the finer details of the symptomatology, one can readily distinguish four phases. They are marked off from each other by sharp and dramatic turns, and each phase has a characteristic theme of its own.[3]

The first phase consisted of an act of self-denial, together with a denial of the world in which the patient had lived up until then. He experienced himself in a new role, and new vistas opened up before him.

This process of self-denial, of “self-betrayal,”  is a familiar one in the neuroses. I have no doubt that this tragic step of giving up oneself in one way or another is crucial and takes place in every neurotic development. It is clearly discernible in every character neurosis as a factual result, and often also as an unconscious intent. However, in the neuroses this self-denial with the resultant loss of personal identity is a slow, insidious, symbolic, and unconscious process; but in the case of B it was sudden, dramatic, and literal.  He actually changed his name; he literally destroyed everything that could identify him, as if to say: ‘”This person that I have been till now  shall exist no more.” This extreme step  strikes one as a grandiose attempt at a problem solution, a decisive choice: “I  give up my right to live my own life, and  hitch my fate to this powerful man; I will  become his satellite.” He gives up his own  will, and all of his actions will be dictated  by another man. He becomes literally an  automaton in the hands of a projected  powerful figure, and as a recompense he  is allowed to share in his glory. While he feels that he is succeeding and basks  in a “glorious feeling,” actually he is reduced  to less than a helpless child. He has to  get “directions” as to whether to walk or stand still, whether to eat or not, and what to eat and how, and the like. When on very rare occasions his own natural impulses break through, as when he “stealthily” stretches his neck to relieve the pain due to a sustained uncomfortable posture, he feels tremendously guilty. He gives up his right for self-determination, to the last minutiae.

The world, as he knew it before, does not exist any longer in its own right, but only as a colossal camouflage for his newly discovered world. And in this new world he is helplessly lost and has to decipher laboriously its meaning in accordance with his delusion. The multitude of ideas of reference and misinterpretations is not  only understandable but inevitable if one realizes how completely B disregards the old meanings, and that things can have a meaning for him only as related to his delusion.

His estrangement from the world expresses, furthermore, a rejection of his family. It is a psychotic solution of a  problem which thus far B has been unable to resolve—namely, to emancipate himself from the ties that were holding him in an unhappy family setting. Interestingly, D, his girl friend, is conspicuously absent from his psychotic preoccupations during the entire course of illness. This may mean a rejection of her in favor of K. It seems to me more probable that it expresses the fact that he is shutting his eyes to that particular problem during his illness.

The conscious correlate of self-denial is a profound disturbance of self-awareness:  the borderlines of what belongs to his own self and what belongs to the outside are obscured and displaced.  Many of the symptoms do arise exactly from this disturbance. His images and thoughts are experienced, as “voices” and “transmitted thoughts “ coming from the outside.  Conversely, independent outside occurrences may appear to him as his own doings, as when he feels that he is sending off airplanes

The beginning of the second phase is marked by a sudden and dramatic change  of the role which K played in B’s phantasy: “I was cheated and deceived. I have been living in a fool’s paradise; K is not a friend but a treacherous and  powerful enemy; he deprived me of my family, of all my possessions—I am in his bondage.” This idea came to B as an illumination, as a sudden flash of insight.   I believe that this is exactly what it was —in spite of the psychotically distorted form in which, it presented itself.  Had it been possible for B at that time to grasp.clearly his dawning insight, he might have said: “Yes, I lived in a fool’s paradise, I have cheated and deceived myself; what falsely appeared to me as a happy  solution was dangerous and destructive to me. I am dispossessed, I lost my hold on this world (deprived of possessions), lost my roots, lost my contact with people (deprived of family), I gave up myself,  my very life does not belong to me— I am in bondage, a slave owned by K.”

Thus, obviously the insight did emerge, but at a time when B was still too deeply lost in his autistic world to benefit from it.  And then the paradoxical thing happened: The voice of his better insight is apprehended in the existing psychotic context and is transformed into a new delusion.[4] Although the emerging insight  had no immediate beneficial effect, it was not entirely lost. In fact, from this episode on, the entire remaining course of the illness can be best understood as a struggle back to health. But the struggle still had to be long and laborious.

For a period of time this new delusion forms the central preoccupation of the patient. He feels trapped and entirely powerless against K’s greed and cruelty.  The hopelessness and despair grow to the point where death seems the only way out.

The suicidal attempt marks the end of the second and the beginning of the third  phase in the patient’s illness. The central theme of the third phase is as follows:  He discovers that there is a way of extricating himself from his predicament. He assumes that a person exists only in so far as he has possessions, some holdings in this world. Though he has been robbed of all he had, there is a way, a technique, whereby he can regain his lost possessions and thereby regain his life and freedom. It seems to me that in spite of the odd phrasing, this idea expresses a fundamental truth, an important insight. It was actually true that B had lost  his hold on his environment. It is also  true that a person cannot really live except in and through his relation to the  world and to other human beings. The  meaning of the odd “swapping” game,  though it appears in the form of a strange  magic procedure, is apparently an attempt  to repossess, to regain a feeling touch with  the surrounding world, to recapture its  emotional meaning and significance.

The other aspect of B’s insight, expressed in his strange ideas and magic  maneuvering, is this: He is not only deprived of possessions and owns nothing,  but he himself has lost his freedom and  is possessed as a slave by K.  In order to  regain his freedom he has to reverse the  process: He has to own something instead of being owned by others as a slave or an  automaton. Thus B’s struggle is to regain  his self-possession, to become the master  of his destiny. He expresses his impulse to liberate himself in still another way: He orders that K be executed so that he may be himself and no longer a slave.

B’s healthy urge toward recovery partly miscarries again. He is still unable to grasp clearly and consciously the voice of his own constructive impulse which, because of the psychotic character of his psychological functioning at the time, is perverted into this new delusion and into a magical practice.

The fourth, and last phase of the illness starts with the experience of an attack of weakness and with B’s realization that something must be wrong with him. This whole phase is occupied with the dawning of an insight into his illness. This insight, like the previous ones, is  first ill-perceived and misconstrued: instead of understanding clearly that he has  lived in a world of phantasy, that he has been mentally ill, he first grasps only part  of the truth: “I am ill”—that is, physically ill. This leads to a period of hypochondriac preoccupations until, in the remarkable experience that marks the end of his psychosis, a clear and full insight is gained.

One may ask whether B has actually gained something by going through a psychosis, or whether his sufferings were  in vain and he simply returned to a state  existing before the illness. If a criterion  is the difference between B’s psychological situation just before and soon after  his illness, I am inclined to believe that  going through the illness did accomplish  a great deal for him. Before the onset of .the illness B is confronted with pressing problems which require important decisions, yet he has no real solution insight.   After his illness he shows no indecision  in attacking realistically his problems, and  he handles them with self-confidence. He  frees himself from the external family  bonds and succeeds in doing this in a way  that is congenial to his personality — namely, without causing any unnecessary  quarrels and conflicts. He tactfully transforms his relationship with K and diminishes its intensity to the point where it  becomes healthy and desirable for him.  He establishes a family of his own and  carries out his occupational responsibilities efficiently. Now he really seems to be  the master of his destiny.

A thread that runs through B’s struggle, both before and during the illness, is the search for a “good father” and a secure, family which he never had. In his illness, although he cuts the ties of dependency to his family—by changing his name and taking on the role of a different person— he succeeds in doing so only by casting his lot with K whom he now unconditionally adopts as the “good father.” After he accomplishes this, however, he realizes in a most stirring manner the dire consequences of losing himself in an overdependent relationship. This realization comes to him in the nightmarish delusional experience of a complete enslavement. He is at the end of his rope, and death remains the only escape.  At that point he really “hits bottom”—an experience which is so often the precursor of  an actual solution. His unfeasible endeavor meets with complete defeat; and  this very defeat of his old motivational pattern clears away the obstacle that has  been blocking his constructive forces.  From here on, he places his reliance in  his own resources, while he is struggling to regain himself and to acquire a place in the world for himself. Thus, the course  of illness telescopes B’s growth from  childish dependence to responsible and self-reliant maturity.

One may ask whether any factors other  than B’s own inner resources contributed to his successful recovery. From all that I know, it was a spontaneous recovery without any great external help. The kind and understanding attitude of one of the hospital employees may have been of some aid to him. However, this aid came at a time when through his personal resources, through his natural drive to recovery, B had already almost reached the goal. Whether going through the his story of his illness with me has contributed to the stabilization of the gain which he achieved by himself cannot be said with certainty.  I feel that our interviews had some therapeutic value in clarifying for him his relations with K.  While in our first interviews he spoke about K in an overidealizing manner, gradually his appraisal of K became more objective; he realized that K’s attachment to him was somewhat excessive and that K’s objections to D were largely determined by jealousy.

In closing this report, I wish to raise a question to which I have no answer, but only  an intuitive guess: Why did this person develop a catatonic schizophrenia, instead of, let us say, a paranoid reaction or a phobic syndrome?  I am inclined to believe that a special type of personality  ‘structure,’ rather than the particular kind of problems, was what determined the “choice of symptomatology.” One of the striking features of B’s personality was something that I cannot define better than an ability to keep things in separate compartments or to pass from one psychological “region” into another—apparently without any carry-over from one to the other. I suspect that this personality characteristic makes possible the psychological feat that is involved in the catatonic reaction. This might also be related to the sharp and dramatic changes that mark the course of B’s illness and are characteristic of most catatonic developments. This same personality factor may be responsible for the fact that in most cases of catatonic schizophrenia there is a sharp, clear-cut, black-and-white lineup of two opposite forces, rather than a complicated net of conflicting tendencies. When one succeeds in obtaining information of the subjective side of the catatonic struggle, one finds almost invariably a battle between two sharply conflicting, irreconcilable forces concerned with ideas of death and rebirth, or a battle between Good and Evil, between God and Devil.

If there is any validity in the hypothesis suggested, the psychological exploration of the personality structure of persons who have had catatonic episodes might yield very valuable information for the understanding of this type of reaction.

BOSTON. MASS.

[1]   A research project concerning neuropsychiatric casualties in the armed forces.

[2] There is not sufficient information for an analysis of B’s personality development and for tracing genetically those factors which finally led to the catatonic explosion. Hence the study of the psychodynamics will not involve the discussion of the psychogenesis, but will be limited to the consideration of the workings of the dynamic factors in the illness itself.

[3] There was no evidence found to suggest  that any of B’s army experiences were significantly related to the precipitation of the psychosis. There were, however some circumstances which may have  had some minor importance. When B arrived In  Florida, he and four other soldiers were placed in  the Instructors’ barracks, presumably because of a  shortage of space in the other barracks. This gave  rise to some wild speculations among the five soldiers about having possibly been chosen for some special task. There was also a rumor among the  soldiers that in the camp there were a number of  secret service agents in the disguise of ordinary  enlisted men. B did not know whether such rumors  had any objective foundation or not. The radar  work itself was surrounded with a certain amount  of secrecy. This and similar items may be considered as having the same function for the development of D’s delusions, as “day residues” have  for the development of dreams: they set in motion trends of associations, but the further elaborations are guided by dynamically more significant factors.

[4] French and Kasanin have called attention to the fact that the patient’s constructive impulse toward recovery may express itself in bizarre delusions.  Thomas M. French and Jacob Kasanin, “A Psychodynamic Study of the Recovery of Two Schizophrenic Cases,”Psychoanalytic Quarterly (1941) 10:1-22.