Onset

Prodromata are almost constant; they possess no specific features: change of disposition, inaptitude for work, insomnia.

Often the symptoms of melancholia open the series of grave phenomena. In themselves they present no pathognomonic features, but consist merely in a state of depression or psychic pain which may be associated with delusions and hallucinations.

Soon the catatonic phenomena proper appear; they may occur also at the onset without being preceded by the period of depression mentioned above. They depend upon a disorder of affectivity, indifference, and a disorder of the reactions, disappearance of the normal will associated with exaggeration of the mental automatism. Clinically they appear in two principal forms: catatonic excitement and catatonic stupor.

Catatonic Excitement

Sometimes, especially at the beginning, it simulates an attack of confusional psychosis or of mania: disordered movements, incoherent speech, impulsive reactions. Soon, however, the nature of the symptoms becomes more definite and the peculiar characteristics of catatonic excitement appear. Its principal features are as follows:

(1) Catatonic excitement is free from any emotion;

(2) It is not influenced by external impressions;

(3) It is not, at least in the majority of cases, governed by definite delusions;

(4) It is monotonous (stereotyped movements, verbigeration).

In other words, the reactions in catatonic excitement attain the extreme limits of automatism.

The spells of excitement occur without cause, in an impulsive and unexpected manner. The patient performs most singular and at times most dangerous acts without being able to furnish any explanation for his conduct even when the attack has passed and has left in his mind a clear recollection of all that he did. A catatonic, perfectly composed an instant before, leaves his bed, seizes a glass and throws it violently at the head of his neighbor. Another breaks to pieces a thermometer imprudently left in his possession. A third calls loudly for a drink of water while holding in his hand a glass filled to the brim. Some display for weeks or months suicidal tendencies without there being any depressive ideas to account for them.

The movements, attitudes, and conversation present stereotypy and verbigeration. Often the patients assume an affected or dramatic air. Their gestures, manners, and fantastic dress frequently survive the period of excitement and persist through the quiet periods and the terminal dementia. Some patients will hop on one foot for months instead of walking; others will invariably respond to all questions by the same phrase; still others will not eat their food without first mixing it up into a disgusting mess; others, again, will walk back and forth on a short path all day long, taking alternately a certain number of steps forward and the same number backward. Such examples could be multiplied indefinitely. Most frequently these peculiarities in the conduct of the patient are purely automatic and remain inexplicable. They are usually not dependent upon delusions. Their origin lies in a perversion of the reactions, and not in any disorder of ideation or of perception. Although delusions and hallucinations are not invariably absent in catatonia, as is insisted upon by Tschisch,1 they are too rare to explain the anomalies of the reactions, which are constant.