or later
manifested by the appearance in the hysteric of conduct or speech
embodying definite and elaborated ideas.

As has been stated fully in the last chapter (to which the reader is
referred), the stupor of dementia praecox is to be differentiated from
that of manic-depressive insanity by the inconsistency of the symptoms
in the former and the appearance of dementia praecox features during the
stupor, such as inappropriate affect, giggling, or scattering. Further,
the nature of the disorder is usually manifest before the onset of the
stupor as such.

Sometimes very puzzling cases occur in more advanced years when it is
difficult to say whether one is dealing with involution melancholia or
stupor. Such patients show inactivity, considerable apathy and wetting
and soiling, and with these a whining hypochondria, negativism, and
often a rather mawkish sentimental death content without the dramatic
anxiety which usually characterizes the involution state. In these cases
the diagnosis is bound to be a matter of taste. In our opinion it is
probably better to regard these as clinically impure types. They may be
looked on as, fundamentally, involution melancholias (the course of the
disease is protracted, if not chronic) in whom the regressive process
characteristic of stupor is present as well as that of involution.

Great difficulties are also met with in the manic-depressive group
proper. So often a stupor begins with the same indefinite kind of upset
as does another psychosis that the development may furnish no clew. Any
condition where there is inactivity, scanty verbal productivity and poor
intellectual performance resembles stupor. This triad of symptoms occurs
in retarded depressions, in absorbed manic states and in perplexities.
Negativism and catalepsy are never well developed except in stupor. So
if these symptoms be present the diagnosis is simplified. But they are
often absent from a typical stupor. Let us consider these three groups
separately.

The most important difference between stupor and depression lies in the
affect. Although inactive and sometimes appearing dull the depressive
individual is not apathetic but is suffering acutely. He feels himself
wicked, paralyzed by hopelessness, and finds proof of his damnation in
the apparent change of the world to his eyes and in the slowness of his
mind. But he is acutely aware of these torments. The stupor patient, on
the other hand, does not care. He is neit