Disorders Of Attention

Attention manifests itself in two forms: spontaneous and deliberate or voluntary. Spontaneous attention, the inferior and less complex of the two forms, consists "in a direction of the being toward the stimulus" or "in a simple and spontaneous fixation of phenomena." Deliberate attention directs the association of ideas and governs the course of representations, allowing each to Temain for a greater or lesser length of time in the field of consciousness; in other words, it brings about voluntary and conscious.psychic activity.

Complete paralysis of attention involves loss of spontaneous attention as well as of voluntary attention. It coexists always with considerable clouding of consciousness, there being no possibility of the production of any state of consciousness without a certain degree of at least spontaneous attention: :

Abnormal mobility of attention consists in paralysis of deliberate attention, spontaneous attention being intact and in most cases even exaggerated. An impression of any kind suffices to distract the mind of the subject, but no impression can fix it. This phenomenon is well illustrated by the following experiment. A manic patient was asked to tell about the death of his mother, which, incidentally, was the cause of his illness. He began: "The poor woman came home from her work in the evening. She was taken with a chill. ..." One of the assistants picks up a pencil from the table in front of the patient. "Hold on! there is a pencil, a blue pencil. . . . Can you draw?" Another assistant begins to cough. " If you have a cough you should take Geraudel's tablets. . . . You know, spitting on the floor is prohibited. . . . That's a fact. ..." The first assistant unbuttons his coat. " I hope you are not going to undress here, that would be improper! ..." Noticing a small rent in the vest of the same assistant: "I guess you have no wife to do your mending! . . . ' This example shows how the mind, deprived of the guidance of voluntary attention, drifts at the occasion of various external impressions without ever becoming fixed.

1 Arnaud. Un cas d'illusion du deja vu ou defausse memoire. Ann. mecl. psych., May-June, 1896.

Disorders Of Association Of Ideas

Associations are of two kinds: voluntary and automatic. Voluntary associations are under the control of attention and are effected in a special order which is determined by a principal idea termed the guiding idea. Automatic associations are, on the contrary, produced spontaneously and without any guiding idea. They constantly threaten to deviate the course of voluntary associations; one of the principal functions of deliberate attention consists in inhibiting automatic associations.

Weakening of attention is closely connected with sluggish formation of voluntary associations. This latter symptom is manifested clinically by slowness of apprehension, and experimentally by lengthening of reaction-time, that is, the time required for a sensation to be transformed into a voluntary and conscious movement.1

Weakening of attention and sluggishness of voluntary associations constitute the earliest and most constant manifestations of psychic paralysis. Combined with insufficiency of perception and with more or less pronounced disorder of consciousness, they bring about mental confusion, a syndrome which may occur as an episode in the course of a great many mental diseases and as a permanent manifestation of an affection known as primary mental confusion.

1 Pierre Janet. Neuroses et idees fixes, Paris, F. Alcan. - Somraer. Lehrbuch der psychopathologischen Untersuchungsmethoden, 1899.

The intensity of this state may be of three degrees:

1st degree: diminished capacity for intellectual exertion, rapid fatigue;

2d degree: intellectual dullness;

3d degree: complete suspension of all voluntary intellectual activity.

Weakening of attention and sluggishness of association may exist alone, as in certain forms of melancholia, and especially in stupor, in which they attain their highest degree. They may also be associated with exaggerated activity of the mental automatism, which manifests itself by an abnormal mobility of attention and by a flow of incongruous ideas (flight of ideas, incoherence), or, on the contrary, by the appearance in the field of consciousness of some particularly tenacious and exclusive representation (imperative idea, fixed idea, autochthonous idea).

Flight Of Ideas. Incoherence

These two symptoms constitute two different degrees of the same morbid process.

Flight of ideas, almost always dependent upon an abnormal mobility of attention, consists of a rapid succession of representations which appear in the field of consciousness without any order, at the occasion of external impressions, superficial resemblances, coexistences in time or space, similarities of sound, etc. One word arouses the idea of another of a similar sound or having the same termination (association by assonance). The following example from a manic case in which the discourse during several minutes was copied verbatim, will show, better than a description could, the character of this pathological phenomenon:

"Now I want to be a nice, accommodating patient; anything from sewing on a button, mending a net, or scrubbing the floor, or making a bed. I am a jack-of-all-trades and master of none! (Laughs; notices nurse.) But I don't like women to wait on me when I am in bed; I am modest; this all goes because I want to get married again. Oh, I am quite a talker; I work for a New York talking machine company. You are a physician, but I don't think you are much of a lawyer, are you? I demand that you send for a lawyer! I want him to take evidence. By God in Heaven, my Saviour, I will make somebody sweat! I worked by the sweat of my brow! (Notices money on the table.) A quarter; twenty-five cents. In God we trust; United States of America; Army and Navy forever! "

Flight of ideas was formerly considered, especially in mania, the result of excessive activity of normal intellectual function; it was believed that the patient, unable to express in words the ideas which crowd into his consciousness, is compelled to leave out a large number of them, and that these omissions cause the disconnectedness of his discourse. In reality this exaggerated activity affects only the automatic intellectual functions and is always associated with a weakening of the higher psychic functions. The essential cause of the phenomenon is to be looked for in a weakness of attention: representation A cannot fix itself in consciousness and is immediately replaced by representation B, and so on.

While in flight of ideas the representations are still associated by their relations, which though superficial are yet real, in incoherence they follow each other without any apparent connection. The following is a specimen of incoherent speech obtained from a case of dementia praecox: "What liver and bacon is I don't know. You are a spare; the spare; that's all. It is Aunt Mary. Is it Aunt Mary? Would you look at the thing? What would you think? Cold cream. That's all. Well, I thought a comediata. Don't worry about a comediata. You write. He is writing. Shouldn't write. That's all. I'll bet you have a lump on your back. That's all. I looked out the window and I didn't know what underground announcements are. My husband had to take dogs for a fit of sickness."

These few lines suffice to show the profound degree of psychic disaggregation which is manifested by this phenomenon.

It is not uncommon for the two symptoms, flight of ideas and incoherence, to appear in succession, or even together, in the same subject, notably in cases of mania, in acute mental confusion, also, though less often, in dementia praecox.

Imperative Idea - Fixed Idea - Autochthonous Idea

We have stated above that mental automatism may manifest itself by the appearance of an idea that is particularly tenacious and exclusive, occupying by itself the field of consciousness, from which nothing can dislodge it.2

The three forms in which this phenomenon may appear have been well defined by Wernicke.3

An imperative idea imposes itself upon the patient's consciousness against his will; he recognizes its pathological character and seeks to rid himself of it. It is a parasitic idea, recognized as such by the patient.

A mother is haunted by the idea of killing her child whom she loves dearly. As she herself states, she can no longer think of anything else; but she recognizes it as a morbid phenomenon and begs to be relieved of it: this is an imperative idea.

A fixed idea, on the contrary, harmonizes with the other representations. Therefore it is never considered by the subject as foreign to the mind or as a pathological phenomenon.

A mother who has lost her child is convinced that if she had given it a certain kind of medicine the child would not have died. This idea does not leave her, appears to her perfectly legitimate and natural: this is a fixed idea.

Fixed ideas form the basis of certain delusional states, notably paranoia.

Fixed ideas are not found exclusively in cases of mental alienation; they are encountered in the normal state as certain tendencies that may be in themselves perfectly legitimate. Such are desire for vengeance, ambition, e,tc.

1 Milne Bramwell. On Imperative Ideas. Brain, 1895. - Keraval.

L'idee fixe. Arch, de Neurol., 1899, Nos. 43 and 44.

2 This form of mental automatism may be termed monoideal automatism.

3 Loc. cit., p. 108.

Autochthonous ideas, like imperative ideas, develop alongside of normal associations. The only .difference is in the patient's interpretation of them; while an imperative idea is recognized by him as pathological, an autochthonous idea is attributed to some malevolent influence, most frequently to some strange personality. If he complains, it is to the police officer and not to the physician. A mother , believes that her neighbor forces upon her the idea of killing her child: this is an autochthonous idea.

Closely related to imperative ideas, autochthonous ideas present a similar analogy to hallucinations; like hallucinations, they are thought to be caused by automatic activity of a cortical center. But, instead of playing upon ai psychosensory center, the morbid irritation occurs in a psychic center. Baillarger designated autochthonous ideas by the term psychic hallucinations.1 This term has lately fallen into disuse, perhaps undeservedly.

Nothing proves more conclusively the kinship of the two classes of symptoms than the frequent transformation of autochthonous ideas into auditory, motor, and occasionally even visual, verbal hallucinations. The analogy between autochthonous ideas and verbal motor hallucw nations led Seglas2 to consider the two phenomena as identical in their nature, the first being but a rudimentary form of the second. This opinion will appear somewhat exclusive if we take into consideration the fact that autochthonous ideas may engender auditory hallucinations3 just as readily as motor hallucinations, and that in many cases they are not accompanied by even the slightest sensation of movement.

1 Marandon de Montyel. Des hallucinations psychiques. Gaz. hebd. de Med. et de Chirurgie, March, 1900.

2 Lemons cliniques sur les maladies mentales et nerveuses.

3 Wernicke, Loc. cit.

Psychic hallucinations generally indicate advanced disaggregation of the personality and therefore point to a grave prognosis.