The systematized type of delusional dementia praecox is met with in three principal varieties:
(a) Persecutory variety; (6) Melancholic variety; (c) Megalomaniacal variety.
The delusions may either appear rapidly, after a brief period of prodromata, or, on the contrary, they may develop slowly, accompanied at first by false interpretations and only later by hallucinations.
The reactions consist in defensive acts; these reactions become gradually weaker as the dementia becomes established.
The dementia is often announced by disaggregation of the personality, with such symptoms as autochthonous ideas, motor hallucinations, stealing and echo of the thoughts, etc. The time of its appearance is quite variable. Multiplicity of hallucinations usually indicates a grave prognosis and points to a rapid evolution toward mental deterioration.
It is not rare to note some degree of excitement appearing in paroxysmal attacks.
At the onset the melancholy ideas present no peculiarity. There are ideas of culpability, humility, ruin, etc., as in involutional melancholia and manic-depressive psychoses. Later they group themselves so as to form a delusional system which persists until the appearance of dementia.
All varieties of psycho-sensory disturbances are met with. The most important are motor hallucinations, which are of quite frequent occurrence and indicate already advanced psychic disaggregation.
Mystic ideas, ideas of possession, hypochondriacal ideas, and ideas of negation are frequent.
Attacks of anxiety, common in the beginning, as they are in all psychoses in which the depressed state predominates, become less and less frequent as the peculiar indifference of dementia praecox establishes itself, and the most frightful delusions often exist without any emotional reaction. As in the preceding form, the mental deterioration often takes a long time to develop.
The ideas of grandeur may either be primary or they may follow a very brief period of ideas of persecution. They assume the most varied forms. The patients claim to be owners of immense fortunes, to be of illustrious descent, to possess remarkable talents, etc.
The hallucinations, which are less numerous and less constant in this than in the two preceding varieties, are always of an agreeable nature. The development of dementia is usually rapid.
The three preceding varieties may combine so as to form four principal mixed types:
Type I: Period of melancholia; period of persecutory ideas; period of dementia.
Type II: Period of melancholia; period of persecutory ideas; period of grandiose ideas; period of dementia.
Type III: Period of melancholia; period of grandiose ideas; period of dementia.
Type IV: Period of persecutory ideas; period of grandiose ideas; period of dementia.
The different periods almost always overlap; melancholy ideas and ideas of persecution, for instance, often coexist; and the same is true of ideas of grandeur and ideas of persecution.
We regret that the space at our disposal is so limited as to preclude citing cases illustrative of all the different varieties of paranoid dementia. We shall limit ourselves to the citation of one case which seems to have reached its complete development and which will give the student an idea of paranoid dementia with imperfectly systematized delusions terminating in mental deterioration.
Louise S., fifty years of age, occupation day worker. The disease came on in 1882. The record of examination at that time shows a state of depression with ideas of persecution and numerous hallucinations. Toward 1886 systematized delusions of persecution had developed, also combined with hallucinations. From 1890 to 1892 the patient had spells of extreme excitement, caused, it seems, by auditory hallucinations; in her excited spells she made many violent assaults on those about her. Since 1894 the delusions lost their systematization.
At present the patient presents a rather incoherent delusional state, consisting of ideas of persecution, ideas of grandeur, hallucinations of hearing and of vision, and characterized by formation of numerous neologisms.
The patient's persecutors are two in number: a man and a woman. They sleep in the asylum at night. But they go out every morning and the patient sees them wandering about in the vicinity of the asylum (visual hallucinations). She sees them "in a by-place, like the trees in the distance." All that she knows about their dress is that the woman wears a black scarf with tricolored stripes at the ends: green and two shades of red. Their name is "Tantan." As they go by they shout "There are the Tantans! There are the Tan tans! " Their remarks contain many neologisms. They complain of being "knaified " (tied together) by a cord which they call "credamina ". When they see the peasants at work they say: "We shall ' charlott' (stroll around), that will be better." They pour out imprecations and threats against the "asilette " (sanatorium): "Nasty asilette! . . . We shall founder the asilette! . . . We shall open fire upon the asilette!" They try to poison the food of the patients, and this spoils the taste of the food and causes symptoms of poisoning. They call the patient "cracked" and threaten to kill her. But she is not afraid of them, as she has authority over them, provided the physicians will give her the power.
On the thirteenth of last February she made them pay 502 francs which they owed her for washing. They are very deeply in debt; they owe especially a great deal of money to the town of Clermont and they are condemned to wander until they have paid off all their debts.
The patient's ideas of grandeur are much more incoherent than those of persecution. The patient has two existences. The duration of the first - which preceded her birth - is reckoned in centuries. The second, which is her "minority," is reckoned as forty-nine years (her real age). She has assumed a fictitious name: Mrs. Schlem, nee Madeleine Vean Marcille. Each human being coming from the hands of God should, according to her, bear a "number of creation." Hers is 2511. Born in Alsace (which is correct), she was brought up in the land of "Frantz," a country like France, only "more ancient and more serious," governed at once "by a republic, a king, and an emperor." She spent part of her life in the "Helvandese" republic. She made her living there by manufacturing desserts. Since then she became the successor of Her Majesty "Anger-guma," the queen of the "Sgoths," a people living between Switzerland S and Switzerland C. She has 59 million francs which she earned by working as a nurse for children and later as a portress. Her wages were 3 francs per day. She was nurse for children for four hundred and seven years. The rest of the time - she cannot tell exactly the number of years - she has been working as portress, which is still her occupation.
All her titles and all her rights are recorded in the "documents of conviction," a book which she has. Information concerning this book is to be obtained from the one in charge of the scullery.
These delusions, though active, at present produce no reaction on the part of the patient and do not affect her lucidity. The patient is quiet and is a useful and intelligent worker. She works in the dining room of her ward, sees that the table cloth is put on at the proper time and that the slices of bread are regularly distributed. After meals she helps to wash the dishes and watches over the work of her helpers. Between meals she works in the nurses' kitchen. On Sundays she writes letters for other patients who are unable to write. The letters which she composes are perfectly sensible, and the spelling is tolerably good, which indicates the conservation of a certain amount of knowledge acquired previously. But her activity is always in the same direction in which it has been for a number of years. The supervising nurse reports that she cannot adapt herself to new work.
Her affections have completely disappeared. Her children, whom she persists in calling her "babies," paid her a visit several years ago." She recognized them, but received them with absolute indifference. She shows no attachment to anyone about her. Whenever any nurse or patient leaves the institution, she simply says: "Another will soon come in her place."