Lecture 23

Abstract

Patient Sch., who you see before you, came only reluctantly to the lecture theatre. He looks around anxiously, comes closer, but hesitantly, and then greets me as an acquaintance. You see him as a 55-year-old, heavily-built man of poor nutritional status, with somewhat cyanotic discoloration of face and hands, and cool extremities, fearful in posture and facial expression. Again and again, he repeats in a rhythmic manner a low moan, and also interrupts his speech every so often, when he shows a great need to express himself. When I interrupt him to give you information, he resents it. He gives correct answers to my questions about his age, family situation, and home town, but you will notice that due to his Affective state, his concentration is impaired; and he introduces pauses, during which he looks around absent-mindedly, so that his answers to simple questions, which would otherwise be quite prompt, sometimes take a long time to reach their conclusion. He also repeatedly suggests that it is difficult for him to concentrate. The impression we gain from his prevailing Affective state is one of bewilderment, anxiety, and disarray. The fact that such Affective states complicate an orderly train of thought has long been known, and has frequently been shown to you. On enquiry we learn that the patient complains of unceasing anxiety. If the seat of the anxiety is in his heart: ‘It wants to crush him’ [W]. He is also breathless, and therefore is sleepless at nights. The patient therefore wished to be examined by me, and in his anxious and overhasty manner, made arrangements to undress. When asked why he is afraid, he tells me of his fear of being beheaded; he had also heard that each day he would receive 50 lashes, counted-out; he would be expected to eat a roll that had lain in a fellow-patient’s spitting glass. On questioning, we hear that other patients lying in the same room with him made these statements. Therefore the patient is well oriented and knows he is in a clinic for the mentally ill. However, he has not judged the current situation quite correctly; and presumably his viewpoint was already rather limited, as we often find among country folk from his region. He knows me; he recognizes the audience as students, and thinks that I have granted them ‘an hour’ [W], but he believes that all men there want to be ministers of religion, like his son, who is currently a theology student and accompanied him to the clinic. On the ward, the patient also claimed that they would cut off his head; he would be taken to the place where corpses were stored. Incidentally, it is not primarily fear from these threats that dominates this patient; rather, we usually hear from him his complaints about the fate of his family. He believes that all his possessions were gone: His son would no longer be able to study. He heard the voice of his young son saying: ‘For three weeks we have had nothing reasonable to eat’ [W]; he had also seen his son standing in front of him, with a pathetic gesture. He believes that his family will all die of hunger; the children are all sickly; his son, the student, was refused life insurance due to heart failure. It was his fault; he had shamed himself by an immoral lifestyle and secret sins of his youth. He had become lazy. He had also harmed himself by chewing a lot of tobacco. The patient tells of an assault, during which he recognized one of his attackers and reported him. He had probably committed perjury at the time, because it had been night, and he could not see clearly. Earlier, when his anxiety was even greater, he also complained that his two youngest children had been poisoned, and his wife had taken her life. At the same time this patient, who has suffered a hernia, eats only meagerly, and says that he gets abdominal pain after a meal.