This is based on:
(a) Early appearance of disorders of affectivity and of the reactions;
(6) Delayed appearance of intellectual disorders proper and their less marked intensity;
(c) The contrast existing in most cases between the delusions and the emotional tone;
(d) The purely automatic character of the excitement and of most of the reactions.
It is at the beginning that the greatest difficulty in diagnosis is experienced.
Mental confusion is to be distinguished by the much more pronounced disorientation, the much more real disorder, so to speak, of consciousness, and by the symptoms of profound denutrition, sometimes of true cachexia, which are a constant manifestation of the disease.
General paralysis is distinguished by the intellectual deterioration en masse, by its characteristic physical signs, and by its special etiology.
Delirium tremens, which may be simulated by the delirious outbreaks marking the onset of dementia praecox, is recognized by the pathognomonic character of the hallucinations* by the very pronounced allopsychic disorientation contrasting with the intact autopsychic orientation, and by the history and physical signs of alcoholism.
Alcoholic hallucinosis is often very difficult to distinguish from the delusional form of dementia praecox. Special attention must be paid to the etiology of the case and to the evolution of the disease, which is more favorable in alcoholic hallucinosis. One should, however, be very guarded in rendering a diagnosis as well as a prognosis. In practice it is not rare to meet with chronic alcoholics who present after an attack of alcoholic hallucinosis or even of delirium tremens the symptoms of dementia praecox which subsequently run the classical course and to which the alcoholism has served merely as a portal of entry.
This is always grave as the usual outcome is dementia.
The mental deterioration is sometimes so slight, it is true, that it appears only as a scarcely perceptible sluggishness of association of ideas, a certain degree of emotional indifference, and a tendency to intellectual fatigue.
A certain number of patients even form an exception to the general rule and recover completely. Such cases are rare and are to be accepted only with extreme circumspection. Many of the apparently complete recoveries are but relative, and many recoveries considered permanent are but temporary; that is to say, they are mere remissions.
Indeed, remissions are frequent in dementia praecox. Their duration varies within very wide limits, from a few hours to several years. It is not exceptional for a precocious dement to come out of his first attack apparently unscathed, resume his normal life for five, six, or more years, suffer a recurrency, and end with dementia.
Dementia praecox is not in itself a fatal disease. It may terminate fatally from some of its complications. The most formidable of these is pulmonary tuberculosis, which is apt to attack patients in a state of depression or in catatonic stupor.
Such is the general prognosis of dementia praecox. But since the possibility of recovery or at least of long remissions exists in some cases, the practical psychiatrist is in every case, considered individually, confronted with the problem of rendering not a general but a special prognosis.
It is difficult, not to say impossible, to predict the course and outcome of a given case. Some features of the disease have, however, been found empirically to be of special prognostic significance, and may therefore aid the physician in forming an opinion.
The first point, one that should never be lost sight of, is that only those cases can be properly regarded as absolutely incurable in which there is actual mental deterioration. In this connection the most certain and most constant sign of mental deterioration is indifference, when it exists independently of any marked disorder of consciousness, hallucinations, excitement, or stupor, in other words, when it exists as a basic disorder. A host of symptoms, descriptions of which have already been given and which need not here again be entered upon (weakening of attention, inaction, etc.), are seen in more or less close association with indifference; it must, however, be insisted on that their significance is subordinate to that of indifference.
Aside from these states of actual deterioration the prognosis should always be guarded. Nevertheless valuable indications may be gained from a study of the combination of symptoms before the development of mental deterioration; for the various forms in which the disease appears and, in the same form, the predominance of one or another symptom, afford very different indications.
There is but little to be said concerning the simple form: consisting essentially of mental deterioration, it may be regarded as incurable from the beginning. The question may arise whether the deterioration will progress or will remain stationary. Unfortunately there is no sign which might aid in forming a judgment on this point.
The catatonic form presents the greatest chance of cure. Kraepelin has observed in 20% of his cases remissions so complete and so lasting as to resemble cures. Other psychiatrists the world over have reported similar results. It seems clear, therefore, that recovery from catatonia is a possible thing.
Catatonic symptoms are not all of the same gravity. In a general way, states of excitement are of lesser gravity than states of stupor, the latter not being, however, always incurable. Negativism, morbid suggestibility, or delusions do not imply a particularly unfavorable prognosis and are capable of retrogression and complete disappearance. On the other hand stereotypy, whether of speech, movements, or attitudes, very marked incoherence, sudden violent and unexplained impulses, not having their origin in a delusion or a hallucination, have an unfavorable significance and generally indicate chronicity, without, however, enabling us to predict the degree of mental deterioration to which the disease may lead. These symptoms would justify us in saying fairly definitely that the patient will not get well, but not that the disease will be arrested in its progress, or that it will advance; this point should always be reserved.
The delusional forms are not all of the same gravity, although on the whole the prognosis of delusional dementia praecox is more grave than that of catatonia. Systematiza-tion of the delusions is almost always a sign of chronicity. We say chronicity, but not tendency toward either rapid or profound mental deterioration; for there are types of paranoid dementia with active and well systematized delusions in which it would be very difficult to detect any trace of mental deterioration. Such cases approach those which are to-day still described under the name of delire chronique without dementia and which have been insisted on by Falret and his pupils, when they have maintained, contrary to Magnan, that the period of dementia may be wanting in that condition. Hence, the indication of systematized delusions is: chronicity very probable, but not necessarily dementia.
This probability becomes even greater when the delusional system becomes impoverished, begins to show features of incoherence and absurdity, and especially when the delusions cease to be accompanied by adequate affective state and reactions. The latter principle is but a corollary of the principle enunciated above, namely, that indifference without an obvious basis is a symptom of incurability.
As signs of unfavorable prognosis in paranoid dementia should be mentioned, further, multiplicity of hallucinations (when occurring independently of mental confusion), in particular psychomotor hallucinations and those of general sensibility, also transformation of the personality.
These are, briefly sketched, the data which enable us in a certain measure to foresee the course in a given case of dementia praecox. One must not be misled into taking the value of these criteria to be any greater than that of provisional landmarks; in the present state of our knowledge skill in prognosis is dependent chiefly upon appreciation of fine shades, which comes only with long experience in mental diseases.
As being of prognostic significance may be mentioned further very decided "shut-in" make-up (see p. 259) and insidious onset, both points being of grave import, while abrupt onset in a subject of normal mental make-up affords greater hope of improvement or recovery.