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In the second group are ideas of persecution peculiarly associated with false interpretations; any chance occurrence is ascribed by the patient to malevolence; he sees in everything evidences of hostility against him, and attributes to the most ordinary and unimportant facts and actions a significance which is as grave as it is fanciful. This form of ideas of persecution is frequent at the onset of certain psychoses; it also constitutes the basis of an affection known as paranoia or reasoning insanity.
Some patients do not know their persecutors. Others accuse some particular persons or societies (Jesuits, Freemasons). Still others bear their hatred towards some certain individual who is, in their eyes, the instigator of all the injurious procedures of which they are the victims, "the great master of the persecutions," as one such patient once said.
Of all delusions those of persecution are the most irreducible and are held by the patients with the most absolute conviction. Almost always the patients resent to have them disputed. In themselves these delusions do not have an invariable influence upon the prognosis, excepting that, in a very general way, they are of more serious import than melancholy ideas.
Of all delusions these also present the greatest tendency to systematization and to progressive evolution. A perfect persecutory delusional system should comprise:
(a) A precise idea of the nature of the persecutions; (b) An exact knowledge of the persecutors, of their aim, and of the means employed by them;
(c) A plan of defense in harmony with the nature of the delusions.
In the examination of cases with persecutory ideas one should always attempt to determine these points, on account of their great practical importance.
Ideas of grandeur. Ideas of grandeur appear chiefly in demented states and are often of a particularly absurd nature, bearing the stamp of intellectual enfeeblement. The patients are immensely rich, allpowerful; they are popes, emperors, creators of the universe. Generally they naïvely claim these pompous titles without being at all concerned by the flagrant contradiction existing between their actual state and their ostensible almightiness. A general paretic was once asked: "If you are God, how, then, does it happen that you are locked up?" "Because the doctor refuses to let me go," he replied simply. It is not rare to see a pseudo-pope obey without a murmur the orders of hospital attendants and assist with the best possible grace in the most menial labor.
Often the patient's attire is in harmony with the title: uniforms of the oddest fancy, multicolored tinsels, numerous decorations, etc.
When the intellectual enfeeblement is less pronounced, as, for instance, in certain cases of dementia præcox, the subject shows more logic in his conduct. He assumes an air of dignity, avoids all association with the other patients, and declines with a contemptuous smile all suggestions of employment.
Ideas of grandeur are also met with in certain acute psychoses, as in mania, for instance, and in certain forms of systematized delusional states without intellectual enfeeblement (Paranoia originaire of Sander).
AFFECTIVITY.-REACTIONS.-CENESTHESIA-NOTION OF PERSONALITY.
§ 1. DISORDERS OF AFFECTIVITY.
PATHOLOGICAL modifications of affectivity are encountered in the course of all psychoses. They always appear early, and often before any of the other symptoms.
The principal ones are:
(a) Diminution of affectivity: morbid indifference; (b) Exaggeration of affectivity;
(c) Morbid depression;
(d) Morbid anger;
(e) Morbid joy.
Diminution of affectivity. In its most pronounced degree indifference involves all the emotions, as in extreme states of dementia (general paresis and senile dementia in their terminal stages), in which it is associated with general intellectual enfeeblement. In its less severe forms indifference is manifested by disappearance of the most elevated and the most complex sentiments, with conservation and often even exalta
tion of the sentiments of an inferior order. The altruistic tendencies are the first to become effaced, while the egoistic sentiments persist. Only the satisfaction of their material wants still concerns the patients and governs their activity. Many take no interest during the visits of relatives in anything excepting the eatables brought to them; they eat as much as they can, fill their pockets with the rest, and leave without taking the trouble to express their thanks or even to bid their visitors good-by.
Morbid indifference may be conscious or unconscious. In the first case it is realized by the subject as a painful phenomenon. The patients often say: “I have lost all feeling, nothing excites me, nothing pleases me, nothing makes me sad." Some complain of being unable to suffer. This state, which may be called painful psychic anaesthesia, is frequent at the beginning of psychoses and sometimes persists through the entire duration of the affection (affective melancholia, depressed periods of recurrent insanity).
In the second case, which is more frequent, the diminution of affectivity is not noticed by the patient. Such is always the case in states of dementia.
The changes of other mental faculties, such as memory and general intelligence, are not necessarily proportionate to those of affectivity. Notably in dementia præcox it is not rare to find a fairly good memory and a relatively lucid intelligence coexisting with complete indifference.
Exaggeration of affectivity. Often combined with indifference, as has been shown above, exaggeration of affectivity is encountered in most mental affections,
congenital and acquired. It constitutes the basis of irritable and changeable moods and of the extreme irascibility so often seen among the insane and among degenerates in general.
In the acquired psychoses it is an early symptom, appearing at times long before the other phenomena. An individual previously calm, gentle, kind, becomes disagreeable, ill-natured, violent. "He is completely changed," is a remark often made by the relatives.
Irritability is almost always associated with variability of moods.
Disorders of affectivity serve to characterize a large and important group of patients included under the somewhat vague designation of "constitutional psychopaths." In these individuals the emotions are entirely out of proportion with their causes. The death of an animal plunges them into unlimited despair, the sight of blood brings on syncope, the most simple affairs preoccupy their minds so as to make them lose their sleep. Sensitive in the highest degree, they see in everything malevolent intentions, disguised reproaches. But their sentiments, though very intense, do not last long; sorrows, enthusiasms, resentments, are with them but a short blaze.
Morbid depression. - Depression presents itself in pathological states, as it does in the normal state, in two forms: active and passive. This distinction is founded upon the presence or absence, or rather upon the intensity, of psychical pain. While in active depression psychical pain is very prominent, in passive depression it is dull, vague, scarcely appreciable. Indeed, as Dumas says, "the element of pain is not absent