Nur Manzil, Psychiatric Centre, Lai Bagh, Lucknow. To a foreign psychiatrist working amongst patients of a different culture, the differences and similarities in the sympto- matology of mental illness naturally pre- sent a fascinating field for studies. By trying to evaluate, how cultural influences are changing a pattern of illness in a parti- cular diagnostic group, one might, more easily than if one only sees patients of one's own country, learn to distinguish, what is accidental and what is essential in a parti- cular type of mental or emotional distur- bance. After my coming to India in April 1956, it did not take me long to notice that, while in Indian patients schizophrenic manifestations often differ considerably from those we are used to in Europe, one can hardly ever go wrong in recognizing cases of manic-depressive illness. I found here the same familiar complaints, the same predominance of pyknic body-types, the same reaction to an attitude of sym- pathetic understanding and patient reas- surance as I had been used to meet in my patients in Switzerland. This confirmed my conviction, which I still keep up in spite of others who refuse to make a dis- tinction between various forms of depres- sion, that manic-depressive illness is a de- finite morbid entity, presumably with some biological foundation. As such it is to be distinguished from reactive depression, neurotic depression, depressive syndromes occurring in the course of other psychoses, involutional depression and a particular Contents of Depressive Ideas in Indian Patients type of depression which is best characte- rized as exhaustive depression. (See also Kielholz (1) ). This classification does not exclude the possibility that occasional- ly we may be in doubt, into which cate- gory to place a particular case. In young patients, e.g., it is often very difficult to dis- tinguish in the first phase of illness, whether a manic or depressive episode is more of cyclic or of schizophrenic charac- ter, while in the elderly patient one may hesitate, whether to diagnose a genuine endogenous mania or depression or to call it an involutional depression or senile mania. Family-history, body-type, pre- morbid personality and ultimate course of the illness often help to make the distinc- tion, where symptomatology alone does not point clearly enough towards a defi- nite diagnostic group. Furthermore, one may of course have to differentiate etiolo- gical or precipitating factors, which in an individual case may suggest more a con- stitutional bias, in some other case a more psychogenic origin. Phenomenologically, however, I find that the patients with manic-depressive illness form a quite cha- racteristic group, which is absolutely com- parable to patients of the same category in Europe. (See also Hoch (2) ). Having been tempted for quite some time to investigate this similarity of manic- depressive patients in Europe and India more closely, I was finally stimulated into undertaking the present study of the con- [Downloaded free from http://www.indianjpsychiatry.org on Friday, November 19, 2010, IP: 14.96.220.85] January 1961 ] Contents of Depressive Ideas in Indian PatientsHoch 29 tents of depressive ideas by a letter from an Austrian colleague, which reached me last summer. Dr. H. Lenz, retired lec- turer in psychiatry, of Lenz, wrote to me, as follows : ( 3) . "For some time past I have been busy investigating the changes to be noted in the psychopathology of the major psycho- ses during the last 50 years. I have just terminated a study on 376 depressions, in which I found mainly that the tendencies towards guilt and suicide are decreasing." Dr. Lenz then makes some remarks on the change in contents of ideas in schizo- phrenic patients and goes on to discuss his findings : "As far as I can see, this change in psy- chopathology is due to a great extent to a change in the spirit of the age. This in- sight again is important for a biologically oriented psychiatry, which ought to con- sider symptoms that are, as far as possible, independent of variations due to the at- mosphere of an age or to psychological situations." "In connection with these problems, I should be very much interested to know, which, nowadays are the main symptoms in melancholia or endogenous depression and paranoid schizophrenia in India, a country or cultural unit which is so diffe- rent from the Western cultural sphere. I can imagine that in India, corresponding to the different attitude of man towards material possessions, religion etc., a quite different spirit might still reign the epoch, and that this might have its consequences also for the psychopathological manifesta- tions of depressions." To this I answered in November 1959, promising to compile some figures about the contents of depressive and paranoid ideas. ''Meanwhile, however," I wrote, "I can already tell you now that any material gained in this way may not necessarily give a valid answer to your questions. We shall only know, what the contents of the ideas of those patients who are already "civilized" enough to come to a psychiatric clinic. . . . Our patients, who come mainly from Lucknow, but also from the whole Province of Uttar Pradesh and beyond, from all over India, are a selection of peo- ple who already have somewhat more en- lightened ideas about mental illness. Apart from this, it is often a mere matter of chance that they have heard about our cli- nic. So one could easily imagine that the very patients, whose ideas still have got a strongly magic, animistic content, first of all would not know about a clinic of this kind, and, even if they knew, would be far more likely to take treatment from some magician, fakir or quack. Apart from this, if one really wanted to be exact, one would have to divide up the observed pa- tients according to religion and caste. It seems a fair assumption to me, that a mem- ber of the caste of merchants may rather have ideas of improvement, while a Brah- min may more easily produce idas of sin- fulness and religious doubt." "Theoretically speaking, or perhaps even when taking certain practical experiences into account, it seems quite plausible to me that the contents of ideas should change with the spirit of the time. If one assumes that, fundamentally, illness usually is in some form an excuse for one's refusing to accept life as it is or to accept oneself as one might be, the "excuse" naturally has to be valid, not only for the patient him- self, but also for his surroundings. A phe- nomen of this kino".has been observed in the change of symptoms in war-neuroses. As soon as some "hiding-place" has been exposed as such by science or public opi- nion, new, and more valid excuses and escapes have to be found." [Downloaded free from http://www.indianjpsychiatry.org on Friday, November 19, 2010, IP: 14.96.220.85] 30 Indian Journal of Psychiatry [ Vol. Ill No. 1 A short while ago he sent me a reprint of a paper of his, entitled : "Introduction to the problems of Diagnosis and Treat- ment of Depressions", published in the "Wiener klinische Wochenschrift'' ( 4) . In this paper, Lenz enters into the ques- tion of the leading symptoms of endogen- ous depressions and their variations in the course of time and in different areas. He states that by older authors guilt-feelings were named as the essential symptoms of endogenous depression. More recently, e.g. in a paper by Von Orelli, (5) pub- lished in 1954 in Switzerland, it has been shown that during the past 75 years guilt- feelings have become less predominant. In his own material, Lenz (4) only found them present in 50% of the cases, while in previous investigations this figure was about 75%. He comments on this : "One would have to conclude from this that guilt-feelings have no immediate con- nection with the essence of depression, but only indirectly. Guilt-feelings possibly are far more due to the concept which the patient has made for himself or taken over from others about God and the world. In some, as yet unpublished, papers I have tried to show up, how the increasing ap- preciation of our "ego" takes a more or less parallel course with a diminution of interest in and attachment to Christian re- ligion. This would also explain the de- crease of guilt-feelings." Lenz then makes a statement, for which he mentions Prof. Urban of Inns- bruck (who has been in India several times and has studied Buddhism at Nalanda University), Prof. M. Boss and myself as witnesses and sources. I cannot quite imagine, how, from my statements which I translated to you, he could have got the following ideas, which certainly misrepresent matters. He writes : "In endogenous depressions of Hindus, and endogenous depression occurs in India just as much as here, no guilt-feel- ings are known, a fact which can easily be explained from the philosophical and religious point of view of Hinduism. When, however, a Hindu who is convert- ed to the Christian faith, falls into endo- genous depression, he too will suffer from guilt-feelings According to Lehmann (6) non-Christian, primitive Africans also manifest no guilt-feelings or self-accusa- tions during endogenous depression. Ano- ther author, Volkel (7), recently seriously questioned the value of guilt-feelings for establishing the diagnosis of an endogenous depression.'' Lenz then turns to the question of sui- cide, which by some authors also has been considered as a central phenomen in the psychopathology of depression. One notes, however, that in certain European regions (the author names Holland and Sachsen, a province of Germany), the fre- quency of endogenous depressions is equal, but the frequency of suicide committed during endogenous depression is quite dif- ferent, in accordance with the rate of sui- cide in the total population of the two countries. It seems that the rate of sui- cide varies in different epochs. From the material of the Central Statistical Office of Austria one has to conclude that during the last 20 years the figure for suicides has significantly decreased. Quite independ- ently of this figure, about which he only- heard later, the author also stated a de- crease of suicidal tendencies during the last 20 years in the 367 depressive patients investigated by him. Lenz assumes that similar variations, due to cultural sur- roundings and the "spirit of the age", might also be proved with regard to other ideas, such as the illusion of impoverish- ment and hypochondriac symptoms. [Downloaded free from http://www.indianjpsychiatry.org on Friday, November 19, 2010, IP: 14.96.220.85] January 1961] Contents of Depressive Ideas in Indian PatientsHoch 31 Noticing all t hese variations in symptoms t hat wer e once supposed to be central and essential, Lenz asks, what , after all this, should be consi dered as "t he fundament al syndrome of endogenous depression, one t hat is present in every depression without regard to person and life-situation, t he im- medi at e and t angi bl e expression of that vital sadness, whi ch K. Schneider ( 8) con- siders as t he ul t i mat e, i rreduci bl e basis of all depressions, and whi ch Wyr sch ( 9) names "motive-less, vital mel anchol i a". Lenz calls t he basic syndrome, which he found in 90% of his cases all t hrough the 50 years of observation, t hat of "complain- ing of bei ng wi t hout " or "bei ng deprived of". He explains it as "a complex syn- drome, t he expression of a loss of all func- tions and relationships of man in this world and beyond it. Loss is t he essential con- t ent of all depression. Newer authors (von Gebsat t el (10) and E. Strauss (11) ), illuminating t he phenomenon of depression from anot her side, have charact eri zed it as a st oppi ng of t i me and t he possibilities for devel opment given by t i me. " Lenz then describes, how this syndrome of "being wi t hout " can start with t he vegetative func- tions, i.e. loss of appet i t e, loss of sleep; t hen comes loss of joy, loss of interest, loss of power of decision, loss of j udgment , loss of activity, loss of pl anni ng, loss of aim, loss of values, loss of meani ng, loss of con- solation, loss of courage, loss of hope, loss of peace and loss of faith. Though such sympt oms also occur in other types of de- pression, t he characteristic feature of endo- genous depression is seen by Lenz in t he intensity and universal extent of t hese com- plaints of "bei ng wi t hout ", also by t he fact thar out war d circumstances pl ay hardly any role in produci ng them. He points out that, in mania, this syndrome of "being wi t hout " is changed into its opposite : t he mani c pat i ent has everything, commands everything, is in contact with everyt hi ng, not only at present, but even in future. Lenz t hen adds, and in this he is qui t e correct, t hat this syndrome of "bei ng wi t h- out' ' is also found in t he depressions of Hi ndu pat i ent s. It woul d of course be begging t he ques- tion to ask, whet her in my case-material, which, wi t h only 53 cases of endogenous depression is perhaps rat her too small, this vital syndrome of "bei ng wi t hout " also is present. In more or less the form describ- ed by Lenz, I actually made it t he crite- rion for classifying a depression as endo- genous, taking into consideration, of course, such factors as family-history, body-type, previous mani c or depressive phases, ul t i mat e course of the illness and response to treatment. So, what I woul d call the "vital syndrome' ' , was present in all t he cases. As I mentioned in t he be- ginning, it is amazing to find, how similar the complaints of Indi an patients are to those one is used to find in the West : t he same decline of all vital functions, t he same lack of faith, hope, confidence, t he same experience of a closed world, of a dark cur- tain that has fallen down over everyt hi ng or of time having come to a stop. It might be interesting t o investigate t he ver- bal forms of expression used to desi gnat e this experience. Our records do not allow in all cases to examine this. But 1 should like to point to the difference in a general way of formulating depressive experience : The term "depressi on" indicates t hat t he subject feels weighed, pressed down. In German we talk about . "Schwer mut ", which perhaps could best be translated as "heavy mood". In Hi ndust ani we hear t he patient say : "Tabi at girti". Whi l e "de- pression" indicates a passive experience of bei ng pressed by some weight from out- side or possibly one' s own weight, "gi r na" seems to be something more spont aneous. [Downloaded free from http://www.indianjpsychiatry.org on Friday, November 19, 2010, IP: 14.96.220.85] 32 It might therefore be considered as some- thing more active. On the other hand, however, an object will fall, if it does not resist the forces that draw it down, while "depression'' may indicate that the pres- sure from above has to be exercised against resistance. To conclude from this, that Indian patients, who, according to usage of language "let themselves fall", might be more prone to fall into depression than the Western patient, who has to be pressed down against resistance, would however be wrong. When last year, in a lecture given at the University Clinic of Psychiatry at Basel (12), I reported about some statisti- cal figures of our Center, I was told that the distribution of cases amongst the vari- ous diagnostic categories was remarkably similar to that registered in Swiss clinics. As to Indian figures, I could not find any material up to now, which would have al- lowed valid comparison with our particular case-material. (I found some figures for Ranehi Mental Hospital : For 194S''49 the figure for manic-depressive psychosis is 4.4 %. for 1949/50 it is 6.3',, , for 1950/51 it is 7. 8' . ) (13) 1 would be interested in getting figures from other clinics with in- and out -pateints. It goes without saying, that our figures can in no way be utilized to gain some idea about the incidence of manic-depressive illness in the total popu- lation. Our own figures are taken from 1190 pa- tients examined between April 19.56 and June 1960. Of these patients, 6.2%, i.e. 74, were diagnosed as suffering from either a manic or a depressive phase of cyclic psychosis, while, just to give one figure for comparison, 27.6' '<of the total figure were patients with schizophrenic disorders. I have not calculated any total figures yet for the other diagnostic categories. I can, however, say that during the last 4 years of Psychiatry [ Vol. Ill No. 1 tbese two figures, for manic-depressive psy- chosis and schizophrenia, have remained fairly constant, while the figure for neuro- tics for instance has shown much greater fluctuations (between 23.9% and 42. 2' . ). Of the 74 patients belonging to the manic-depressive group, 53 were first exa- mined during a phase of depression, 21 during a phase of mania or hypoinania. Of these ,53 depressive patients, however, 5% of the men and 30' . of the women also had gone through manic phases at some time or other, while 24' . of the patients first observed in mania also had experienc- ed depressions. It may be interesting to compare this incidence of manic phases with a figure given by Kielholz, (1) who found that 34' < of his depressive pa- tients had also gone through manic phases. My closer investigations only concern 50 of those patients who were seen during a definite depressive phase. 20 of them are men, 30 women. (This ratio of 60' . wo- men approximates to that named by Bleuler (14) which is 70% women against 30% men). Going through the case-histories, I tried to list the contents of the patients' depressive thoughts according to different headings. In Europe, we usually distinguish three main categories of depressive ideas; hypochondriac ones, concerning the physical integrity of the pa- tient; ideas of impoverishment, concerning the material circumstances; ideas ol guilt and sinfulness, pertaining to the moral and religious sphere. In addition, of course, one finds suicidal ideas, doubts about reli- gion and paranoid elaborations. When trying to group the ideas expressed by my Indian patients, I found it convenient to establish the following categories, which I shall indicate in the order of their fre- quency (See Table 1). Indian Journal [Downloaded free from http://www.indianjpsychiatry.org on Friday, November 19, 2010, IP: 14.96.220.85] Janury \?6l \ Contents of Depressive Ideas in Indian Patients Hoch 53 BODY PAMIEY WORK SUICIDE GUILT MIND RELIGION PARANOID POSSESSIONS CONTENTS OF DEPRESSIVE IDEAS All Patients (50) 1 I / 50j j Al l Men (20) Al l Women (30} BODY FAMILY WORK SUI CI DE. GUILT MIND RELI GI ON PARANOID POSSESSIONS J m 50* < Hindu Men (18) Hindu Women (25) BODY PAMILY WORV SUICIDE GUILT MIND RELIGION PARANOID POSSESSIONS T 3 50 A
English spea- king , educated JVcrnacular edu- c a t i o n , citjr Li t t l e or no edu- cat i on, vi l l age Table 1 : Shows the contents of depressive ideas in order of their frequency. In the separate graphs for Men and Women and Hindu Men and Hindu Women, the educational status is indicated by different marking, as indicated above. The 50% line refers to the total number of patients in each group. [Downloaded free from http://www.indianjpsychiatry.org on Friday, November 19, 2010, IP: 14.96.220.85] 34 Indian Journal of Psychiatry [ Vol. Ill No. 1 78% of the patients had ideas concern- ing the body and its functions. Some of these of course merely represented a more marked or even exaggerated concern about the basic vital symptoms, such as sleep- lessness, lack of appetite, weakness; but most of the patients counted in this group expressed definite hypochondriac ideas. 58% of the patients were worried, in some way or other, about the welfare of their family-members. This, perhaps, is a fea- ture which one would not expect with such regularity in Western patients. 38% of the patients, mainly the more educated ones, felt uneasy about their work. 36% of the patients admitted suicidal ideas; some of them had even been saved from attempted suicide. Fairly close to the frequency of suicidal ideas come the feelings of guilt and sinfulness with 32%. 20% of the pa- tients were preoccupied about their mental functions, either fearing that they might go mad or worrying about lack of con- centration. In 18% of the cases we found some paranoid elaborations, and in an equal percentage of cases the patients felt that their religious faith had been destroy- ed or weakened by the illness. Definite ideas of impoverishment or worrying about material possessions were only present in 16% of the cases. "- One must of course add that the ideas we were able to list in this order are only the ones which our patients either voiced spontaneously, or which they admitted on being asked. It is very probable that shame, embarrassment, fear of violating convention, may have prevented many pa- tiepts from exposing their more secret ;l\^prehensions and doubts. Some of the patients only revealed their most upsetting thoughts after several interviews or even only when the depression was lifting or practically overcome. Much may also de- pend on the way one asks the patient about his complaints. Recently, since I had started on this study, I have taken more care to ask depressive patients about the various spheres their thoughts might have turned to. Their response to my inquiries has given me the impression that guilt- feelings, for instance, might be far more frequent than one would conclude from the patients' spontaneous accounts. Though the results of splitting such a small number of patients into even smaller groups may be rather doubtful, I attempt- ed to investigate my figures with regard to sex, age, educational status, religion and caste. If we keep in mind the sequence of the depressive themes in order of frequency, our group of 20 men mainly deviates from the general pattern by a predominance of concern about material possessions over paranoid ideas. The other themes keep their place, though not quite with the same proportions. In more than 50% of the men, preoccupations about body, family, work and suicide are present, whereas the theme of guilt follows with a greater dis- tance than in the whole group, keeping closer to the figures for mind, religion, paranoid and possessions. If we want to adjust the sequence so as to reflect the frequency of the different themes in the 30 female patients observed, we find again that the curve follows the general pattern, as far as body and family are concerned. The only preoccupation, however, which is present in more than 50% of the female patients, is that about physical integrity. On the whole we find amongst women fewer themes associated in one and the same individaul than amongst the men. There are quite a number of cases amongst the women, in whom, apart from the vital syndrome, depressive preoccupation only concerns one single sphere of life. The third place, after body and family, is taken [Downloaded free from http://www.indianjpsychiatry.org on Friday, November 19, 2010, IP: 14.96.220.85] January 1961] Contents oj Depressive Ideas in Indian PatientsHoch 35 by the guilt-feelings; then come work and suicide in the same sequence as amongst the men. The order of the remaining themes differs completely from the pattern amongst men: paranoid elaborations occur as frequently as ideas of suicide and al- most as frequently as those concerning re- ligious faith, whereas worries about mate- rial possessions take the same place as the fear of losing one's mind. (See Table 1). It is, however, very doubtful, whether the variations in the two curves for the male and female patients really represent a true pattern of sex difference. If we consider the educational status of our patients, we find that all of the men ex- cept one had had an education which en- abled them to express themselves freely in English. Amongst the women, only one third had had an approximately equi- valent education. Of the 20 remaining female patients, 12 were from cities with some vernacular education, 8 were village women with little or no education. While depressive preoccupation with body and family occurs in almost equal parts in all these 3 categories of women, again prov- ing the high degree of universality of these two themes, concern about work and balance of mind is found only in the more educated groups. The themes of suicide and guilt are present in fairly equal pro- portions in all three educational groups, while paranoid elaborations and worry about material possessions are slightly more pronouned in the group of village women, religious ideas, on the other hand, more in the highly educated group. Again, however, these differences might not be quite typical for these educational groups, at least not amongst the women. We have to consider that 40% of the most educated women are Christians, 2 of them Anglo-Indians. This factor may signifi- cantly change the picture. If we only consider the Hindu women, leaving out the 4 educated Christians and one primi- tive Muslim woman, paranoid ideas take the same place as guilt-feelings, followed closely by ideas concerning work and sui- cide, while doubt about religious faith comes last, leaving preoccupation with mind and possessions in an equal position. Amongst the male patients there was only one Christian and one Muslim. Leaving out these two patients, the Hindu group does not show any essential deviation from the total of men. (See table 1) While mentioning religion, it may be in- teresting to note that, though the percent- age of Christians and Sikhs in the manic-de- pressive group corresponds quite closely to their proportion amongst the total number of our patients, the share of Hindus amongst the manic-depressive patients with 81' < is higher than the percentage of Hindus amongst the total of patients, which is 69. 1%. The proportion of Muslims amongst the manic-depressive group is with 6.7% considerably lower than the Muslim share in the total of patients, which is 17. 1%. If we count depressions only, the Muslim share is only 3. 8%, which is only one quarter of the percent- age of Muslims in the total case-material. An attempt at dividing the patients into- two groups according to age: one of the patients below age of 35, one of the pa- tients above 35 years, shows up some dif- ferences. It is however, doubtful, whether they are significant. While all of the men below 35 thought of suicide and 50 %> of them expressed guilt-feelings, less than half of the men above 35 seemed to con- sider these possibilities. In both men and women, paranoid ideas and religious doubts were definitely more frequent in the older age-group, while guilt-feelings and apprehension about mental balance seem to worry more the members of the [Downloaded free from http://www.indianjpsychiatry.org on Friday, November 19, 2010, IP: 14.96.220.85] 36 Indian Journal of Psychiatry [ Vol. Ill No. 1 younger generation. As, in the female group, more of the highly educated pa- tients are to be found amongst those above 35 years, these latter figures might of course point to a greater self-awareness amongst the younger generation, quite indepedently of educational status. We might, in this case be allowed to conclude that the growth of consciousness of self, stimulated through the recent cultural changes in this country, have by now led the younger generation to a stage, from which Western patients, according to Lenz and others emoted by him, are already departing. In the process of becoming conscious of himself as a separate, respon- sible unit man, when falling into depres- sion, first seems to have to turn inward in ideas of self-incrimination and self-des- truction. Then, however, if we are to ac- cept the Western figures given by Lenz, which indicate a decrease of suicidal ideas and guilt-feelings during the past 50 years, If a person becomes more jittery and anxious after taking tranquilizers, the drug may have worked too well and on the wrong system. In a study of 4,000 patients taking tran- quilizers, Dr. Frank J. Ayd, Jr., chief of psychiatry at Franklin Square Hospital in Baltimore, Md., U.S.A., found 500 patients with symptoms ranging from muscular weakness and anxiety to laboured breath- ing and grotesque body contortions. Most of the blame fell on the phenothia- zine group of tranquilizers, Dr. Ayd re- it looks, as if man again departed from this pattern, perhaps once more to turn his aggressions and aspirations outward. It may, of course, not be permissible to draw such conclusions about the changing con- tents of depressive ideas from a mere com- parison between patients of two different age-groups. The process of ageing it- self, no matter during which epoch and under what "spirit of the age", is quite likely to change the character of depres- sive ideas too. But, in that case, would one not rather expect an increasing inter- nalization with increasing age, particularly in view of the Hindu tradition of the 4 Ashramas? In our case-material, however, the depressive manifestations that are most definitely turned inward, i.e. those con- cerning guilt, suicide and mental balance, are all present in a distinctly higher per- centage amongst the younger patients. (To be continued) ports in Psychosomatics, the journal of the Academy of Psychosomatic Medicine. These drugs can distort or interfere with normal muscular activities by disrupting the system which co-ordinates movement. Although such symptoms may occur at any age, the changes are greater as age increases. The reactions can be controlled by giving Akineton, a new drug developed for treatment of Parkinson's disease, Dr. Ayd said. Science Digest-Oct. 1960. Page 26. > * TRANQUILIZERS GIVE TITTERS TO SOME [Downloaded free from http://www.indianjpsychiatry.org on Friday, November 19, 2010, IP: 14.96.220.85]
Totem and Taboo: The Horror of Incest, Taboo and Emotional Ambivalence, Animism, Magic and the Omnipotence of Thoughts & The Return of Totemism in Childhood
Schizophrenia - Sick search engine the brain: Neurotic-psychotic developments: When the soul "googles" and the memory delivers increasingly irrational search results