BORDERLINE MENTAL CASES


There is no clear-cut symptomatology but rather certain deviations from the normal which can be definitely defined. It has its origin principally from hereditary factors, viz., insanity in parents, feeblemindedness, epilepsy, consanguinity neuropathic and psychopathic strain in the lineage. It is well to mention here that the word psychopathic is used synonymously with constitutional.


This paper is a feeble attempt to make a brief survey of mental disorders near the stage of insanity or not definitely insane.

There is no satisfactory definition of insanity. To give some idea of what character of cases we wish to exclude, we will not consider cases that in their environmental reaction modify or pervert the actual which amounts to a flight from reality. A more generous concept of insanity might be those cases demanding custodial care because of their mental incapacity for social adjustment. Thus, we will consider maladies under which the patient is able to perform the essentials for everyday living but cannot satisfactorily adjust himself to his requirements for a normal life.

Two groups will include almost all the cases for our consideration, viz., the constitutional and the psychoneurotic types.

The first type lacks moral sensibility, emotional control and the inhibitions of the will. As implied in the term constitutional type it is an imbalance of the mental traits on a constitutional basis. On the other hand it is not a disordered function, something superficial in character.

There is no clear-cut symptomatology but rather certain deviations from the normal which can be definitely defined. It has its origin principally from hereditary factors, viz., insanity in parents, feeblemindedness, epilepsy, consanguinity neuropathic and psychopathic strain in the lineage. It is well to mention here that the word psychopathic is used synonymously with constitutional.

It is suggested by some that the ill health of the mother during pregnancy, including the toxaemias, septicaemias and various infections, is of definite importance. Some symptom pictures similar to the hereditary causation are acquired from long continuance of the toxic effects of drugs and poisons or from the imbalance and dysfunctioning of the endocrines. Also the vitamin deficiencies in the diet may play a part, if they are not the whole cause, in bringing about the psychopathic state. Finally any disease that is capable of affecting the brain of the young and adolescent may leave a cerebral defect resulting, in later years, in character deviation.

The symptom pictures will simulate in appearance a manic minus the spirited emotional element and the hysteric, the neurasthenic, the psychasthenic or the obsessive when present on a constitutional basis.

From an instinctive source we have specialized drives, viz., the pathological liar and the persistent thief or kleptomaniac. Then there are the swindlers who have attractive fly-by-night schemes that fool a part of the people a part of the time. The cranks and eccentric individuals are sometimes brilliant promoters of projects only to have their plans peter out from lack of purpose or capacity to reach their goal. The sexual instinct gives an erotic expression in the homosexual, onanist, sadist, masochism, fetichism, etc. The reactive or situation cases are found among persons in close confinement as in our penal institutions. These may be in character hysteric, catatonic, paranoid, manic or depressed according to the inherent tendency of the individual. And as we may naturally expect, these reactive states disappear upon removal of the rigorous incarceration.

There are cases called constitutionally inferior which are ofttimes associated erroneously with the psychopathic personality. In the psychopath, the inferiority status is in the driver or an uncontrolled will but the intellect level may be normal, or as sometimes is the case, supernormal. The reverse is true in the constitutional inferior where the mentality is subnormal, frequently with physical anomalies. The emotions are proportionately limited with the lowering of the intellect level as from the moron, the subnormal level, to that of the idiot.

In due respect to these constitutional inferior cases they are considered among the borderland ones when they are a menace to society. They almost invariably manifest physical, intellectual, instinctive and emotional defects early in life. In advanced years they will develop reactive psychic disturbances because of the insufficiency of their inferior physical and psychic equipment to meet the normal adult social standards. The symptoms are varied and ill defined and generally labelled behavior disorders.

In summing up the constitutional or the psychopathic type of case, we may well say that there is a constitutional drive featured in the imbalanced state of the mental mechanism.

The psychoneuroses or the disordered functional group have maladies that are not frequently committed to state mental institutions. This is the broadest field to mental disorders taxing the resources of the general practitioner.

It is well established that the mechanism of the neurosis dwells on the psychological plane. From a mental standpoint the individual either fails or lacks the ability to select and control the thoughts coursing through the mental processes, accompanied by an emotional stress or by an inadequate energy output.

Although he is abnormal mentally, he is capable of knowing that this is so and for the time being he feels helpless to master his difficulties. He reacts to conditions in his environment as being real but inadequately so. The symptoms are mentally projected into the physical, the sensory, the motor and the visceral fields. In some instances, these are all combined as in hysteria.

Compulsion neurotics, as a rule, are superior persons striving inefficiently to attain to high ideals. They frequently have fears, doubts and persistent abstract ideas: misophobia (fear of infection), syphiliphobia (fear of syphilis), claustrophobia ( fear of closed places), aerophobia (fear of high places), pyrophobia (fear of fire), agoraphobia (fear of open spaces). A compulsion of doubt may mean a person beset by two courses of action: after the gas is turned out before going to bed, he is seized with the doubt, while in bed, as to whether he really did or did not turn out the gas; to satisfy himself he must make personal investigation.

Persistent ideas are prevalent at night, on going to sleep. Imperative ideas or obsessions are a form of compulsion neurosis, or classically termed psychasthenia. The compulsive phenomena has many varied motor, sensory and sexual symptoms. Impressions from sexual experiences of early childhood give a large number of compulsive disorders later in life.

If there is any feature in a physicians practise that throws him into a state of anxiety, making him a neurotic for the time being, it is the oldest of neuromental phenomena, hysteria. The etiology is not definitely known. Freuds theory continues to possess the field, viz., that hysteria is due to the operation of buried sexual complexes. There has been a repression by diversion and suppression of infantile sex desires into the subconscious by meticulous environment. Thus we have a buried complex. The tension of the desire continues to enervate the more subtle psychic forces, when under an emotional stress the now erotic fantasy emerges upon and through the various physical components. Thus we have what Freud terms a conversion of the effect of the complex into physical symptoms. Furthermore, he declares this is the essential feature of hysteria.

The patients in true hysteria are suggestible and they will become increasingly dramatic when sympathy is extended to them. The symptomatology is very complex. It is grouped about the motor and sensory functions to simulate practically every known neurological syndrome of disease.

Here it is well to bear in mind that the complex of symptoms are not constant but suddenly changeable in location and vary with different periods of observation. There are all degrees of expressed hysteria from the universal distribution of the symptoms in the motor, sensory and visceral fields to a mild delirious state. It may be narrowly confined to a special function as that of smell. Bear in mind, this phenomena is purely mental and it is impossible to define its limits with any degree of accuracy.

The last and undoubtedly the most widespread form of neurosis is neurasthenia. Fatigue is the keynote. The patient has a sense of weakness or exhaustion. Rarely does organic disease exist. What is most prevalent is abnormal physiology. The immediate influence of the fatigue is to lessen the psychic tension and diminish the physical energies. Mentally, there is inattention, especially to things in his environment. When effort is exerted to center his thought processes toward some particular objective irrelevant thoughts intrude against his wish at the exclusion of thoughts which are related and logical to the objective. Thereby he lacks concentration and he makes inadequate contact with things of the external world.

The first stage of fatigue in neurasthenia is the inverted attention on the subjects physical body interests. Fatigue may be either pathophysiologic or psychogenic. If physiologic, there are metabolic changes or changes from lack of nutrition or from emotional stress as fear and physical exertion. If psychogenic, it is a case in which some desire or ambition has been suppressed and unconsciously it is disguised by the attention featuring and complaining of feelings of fatigue. With the lack of concentration to outside interest and with the awareness of fatigue, the individual become self-conscious.

As man is made up of a sum total of many loose parts with the well balanced adjustment of the same to be normal, apprehensiveness of his uncertain state engenders self- consciousness and throws into a chaotic state the numerous component parts in the psyche. This proves to be alarming to him and he accumulates many and varied erroneous ideas regarding his many parts. He continues to dwell and ponder in this fashion until he builds in his mind the symptoms of nearly every known ailment or disease. Enlarging on his morbid sensations and physical ailments he ignores the fact that his difficulty lies in the state of his mind.

Some of the accompanying physical symptoms are: headache, characterized by sensation of pressure or a band-like sensation around the head; sweating of the hands and the feet, sometimes of the axillae and face; epigastric pulsations due either to gas in the stomach or from excitement and physical exertion; tremors of the extremities and photophobia due to the dilatation of the pupils. Spinal irritation or sensation of heat, pain and weakness. An added physical aspect to a neurasthenic is his underweight with flabby muscles. The skin is sallow with an anxious expression and dilated pupils. Acne may be present from faulty elimination. A coated tongue and an offensive breath are commonly present. The cold clammy hands and feet are ofttimes cyanotic, suggestive of hypotension and a low tension pulse. Organic disorders may accompany or predispose the train of neurasthenic symptoms. It is well to examine physically every case to avoid confusion.

Mentally, there is insomnia of a worrisome type. He worries because he cannot sleep and does not sleep because he worries. Forgetfulness is undoubtedly due to the fact that the imagination did not sufficiently register on the memory centers because of the inattention from fatigue. Pessimism runs as an undercurrent through the symptoms with fits of irritability. Fear and apprehension intermingle to increase his difficulties. Being too absorbed in his personal problems he lacks decision.

The causes of neurasthenia are multitudinous. Jeliffe and White in Nervous and Mental Diseases stress the importance of masturbation. They consider it essentially an auto-erotic phenomenon. When this habit begins with puberty to an excessive degree there is danger of the physiological and developmental level in this period of life to remain the same throughout adult life. Normally there are transitional stages in the placement of sex interest. The first is the infantile period — the period of self–discovery when it becomes aware of such a thing as sex instinct. When the child fondles its genitalia erethism is focalized upon the organs. The young life then emerges from this auto-erotic period by placing his interest on members of his family most like himself of the same sex. Passing from this homosexual period he enters the one of puberty where a critical and highly important change ensues. From youth into manhood, love instincts are given out to the opposite sex, outside of his family.

The consequences are readily seen should the psycho-sexual development be stayed or fixed at any of the intermediate points. This seems to be the function of excessive masturbation to fix the narcissistic or homosexual periods. The individual then becomes too much occupied with himself and fails to deal sufficiently with the outer world interests. He becomes a misfit in adult life. Sensing this he loses self-esteem and sinks deeper into self-isolation. Then follows a deficient energy output but an excessive or inadequate discharge of energy is present in the physical sphere.

Francis W. Sinkler in the latest edition of the Cyclopedia of Medicine, edited by Piersol, briefly drops this subject of sex etiology by a short paragraph ending by saying: “It is generally considered that no temporary or permanent injury results from onanism, unless the act is accompanied by, or causes the development of, anxiety”.

It may be well not to stress any one of these viewpoints at the exclusion of the other, for certainly the onanist tends to become an introvert or self-centered and furthermore when confronted by a new business venture or starting on the uncertain course on the sea of matrimony he becomes greatly embarrassed, worrisome and apprehensive.

We should not ignore other causative factors inducing drain on the nerve energy; strain as excess activity, lack of proper amount of rest, the monotonous drudgery of a vocation without a vacation; prolonged mental stress, surgical operations, accidents; worry and anxiety of long duration.

Sinkler mentions heredity. The neurotic and psychotic ancestors are likely to give their offspring unstable nervous system or lowered nervous tone. He also mentions environment such as association with abnormal parents, the lack of self-restraint, the dissipation of nerve energy in vicious habits.

Now passing on to anxiety neurosis, which is an excessive excitation of discharge of energy. True to the name, all the symptoms are grouped about the cardinal symptom– anxiety. At first one might think it is of psychic origin. However, it arises from the physiological plane and attaches itself to an idea or ideas or without ideation. In this, it is different from fear which is related to and activated by some definite external object or some abstract idea entertained in the mind.

The etiology in anxiety neurosis, which is an excessive excitation of discharge of energy. True to the name, all the symptoms are grouped about the cardinal symptom– anxiety. At first one might think it is of psychic origin. However, it arises from the physiological plane and attaches itself to an idea or ideas or without ideation. In this, it is different from fear which is related to and activated by some definite external object or some abstract idea entertained in the mind.

The etiology in anxiety neurosis is fully as interesting as in neurasthenia. It is worth while here to quote Freud: “In some cases of anxiety neurosis, no etiology can readily be ascertained. It is noteworthy that in such cases it is seldom difficult to demonstrate a marked hereditary taint.” Then he continued to say where the assumption of the neurosis is acquired, sometimes after laborious examination the etiology is based upon a series of injuries and influences from sexual life. He even goes so far as to set aside all cases of a doubtful or different etiology so preponderately demonstrated is sexual etiology of anxiety neurosis. To deal precisely with this etiological problem, the sex life and habit must be thoroughly gone in to. In the case of marital relations, it will be a problem situation shared equally by male and female.

The symptom group of anxiety neurosis is accompanied by a physiological disturbances of palpitation, sometimes pseudo- angina pectoris, disturbances of respiration, profuse perspiration, trembling and shaking, dizziness, diarrhoea and vasomotor changes.

In commenting on the borderline mental disorders, one readily recognize no distinctive types or syndromes unless it is in the psychopathic constitutional group. Many cases may present an admixture such as anxiety-neurasthenic, hysteroneurasthenic.

TREATMENT.

This is probably one of the major problems confronting the general medical profession, all the more so from the fact that the concept of mental troubles is rapidly changing. It is known that there is such a thing as purely disordered mental mechanism independent of any apparent physical basis; in other words, there may be a severe mental disorder prior to any physical alternation. We are gradually removing the old idea that there must be organic tissue changes to produce symptoms of any character.

The physicians viewpoint and attitude must truthfully be related to the situation at hand. His personality, tact, knowledge as well as skill will be on trial. He should have a friendly and dependable attitude. Ridicule, commands, deception, argument, has no place in the technique. If he is emotionally inclined, let him recondition himself! Sympathy and scolding will be entirely out of place, and the chances are the patient has had a generous amount of both from relatives and friends.

It is first necessary to make a friendly contact to elicit and command the confidence of the patient. It is well to be passive and receptive, but at the same time deeply interested. Encourage the sufferer to unload all of his or her troubles. Quietly lead them along should they hesitate and only interrupt to set them right on their course should they wander from the matter in hand. All this time there will be ample opportunity to judge the patients attitude whether friendly or cold, irritable, antagonistic, suspicious, aggressive, shrinking or indifferent. Observation of his posture and his facial expression will give some impression as to the success in his personal response.

From here it will be impossible to be specific in outlining treatment. Every case must be adjudged and treated on its own merits. In other words, individualization is always before our minds eye. Should the afflicted one be seriously concerned about his abdominal or cardiac condition, attempt should be made promptly to discover if any real cause for anxiety exists. It may be advisable to make a complete physical examination. This will be a means of establishing rapport and a basis for further therapeutic procedure. Sometimes the patient will be engrossed in expounding his social or religious situation; then, possibly, it would be out of the question for a physical checkup. This can be deferred easily to the time of the second, or even the third, visit.

In regard to frequency of visits, the ordinary case will do well to begin with fairly frequent visits as three a week. There are some good reasons for the frequency in visits; generally speaking the physicians with as many different forms of treatment that if there is too wide an interval of time between the first and second visit, the patient may discount the value of his new physician in the light of his previous one.

It is a good plan to implant a strong sense of anticipation in the mind of the patient, that there is more in store for him that is good, and yet refrain from telling him all that he would know.

Comprehensively speaking, all cases should be considered from the standpoint of their social, moral, mental, physical and spiritual nature.

The physical situation may be found due to the patients starting the day wrong. Insomnia may be the offending factor. He retires too late, or possibly too soon following the evening meal; coffee or tobacco may be the disturber. It was recently scientifically proven that one hours sleep before midnight is as much value as two hours sleep after midnight. It may be noisy where he sleeps or his bed partner may be restless. Possibly there are other factors that might cause the beginning of the day with fatigue.

It is a common custom to retire late and arise late with a snatch of breakfast, then rush to business. At noon with business off his mind, his old enemy fatigue returns. He is then in need of strong coffee, coca-cola, cigarettes or alcohol as a bracer. Sometimes they are bunched together.

If blessed in a financial way he is likely to eat too much or too rich food, consequently he was a spell of drowsiness and irritability for his afternoons work. There may be too little exercise for the amount of sedentary pursuits. Then again there are the food fadists that need common sense advice. All of these, and many more health suggestions may contribute to improving the patients condition.

As previously mentioned, the erroneous sex life plays an important part effecting neurosis. This condition should be thoroughly investigated and dealt with to remedy the evil effects. It is not enough to insist on discontinuance of their perverted practices. The whole scheme of living must be raised to a higher plane. Noble and lofty ideals should be instilled into their mentality. Hydrotherapy, exercise and in some cases bland diet will be helpful. Sometimes a change of surroundings will be of untold benefit. This will awaken new interests and be a means of building into the daily life healthy viewpoints. In some cases the rest cure will acts as a tonic and a restorative.

A rational approach to his problem will be of significant value. Suggestions, persuasions, re-education, intellectual diversion and occupational readjustment can be most readily employed to suit the individual case.

Suggestions are used in all forms of treatment, whether intentionally or not. The victims sole purpose is to seek aid. For this reason he is highly susceptible to suggestions by sympathetic friends, relatives, nurses and physicians. Whatever the advice or instruction given, the attitude of optimism should go a long way to hasten a favorable outcome. Unfavorable symptoms should not be mentioned or they should be minimized. It is admitted that a working knowledge of the patient involved is essential and the physician should judge his own personality and skill.

V. T. Carr