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Full text of "Personality And The Behavior Disorders Vol II"

PERSONALITY

and the

BEHAVIOR DISORDERS

A HANDBOOK BASED ON EXPERIMENTAL

AND CLINICAL RESEARCH

Edited by

J. McV. HUNT

DIRECTOR, INSTITUTE OF WELFARE RESEARCH, COMMUNITY SERVICE

SOCIETY OF NEW YORK. FORMERLY, ASSOCIATE PROFESSOR OF

PSYCHOLOGY, BROWN UNIVERSITY

VOLUME II

THE RONALD PRESS COMPANY < NEW YORK

Copyright, 1944, by

THE RONALD PRESS COMPANY

All Rights Reserved

The text of this publication or any part

thereof may not be repioduced in any

manner whatsoever without permission in

writing from the publisher.

12.

Library of Congress Catalog Card Number : 44-2163

PRINTED IN THE UNITED STATES OF AMERICA

CONTENTS

VOLUME II

PART V

DETERMINANTS OF PERSONALITY EXPERIENTIAL

AND SOCIOLOGICAL

CHAPTER PAGE

20 INFANTILE EXPERIENCE IN RELATION TO PERSONALITY

DEVELOPMENT 621

By MARGARET A. RIBBLE, M.D., Dementia Praecox Re-

search, Scottish Rite Foundation

21 CHILDHOOD EXPERIENCE IN RELATION TO PERSONALITY

DEVELOPMENT 652

By Lois BARCLAY MURPHY, Ph.D., Department of Psy-

chology, Sarah Lawrence College

22 ADOLESCENT EXPERIENCE IN RELATION TO PERSONALITY

AND BEHAVIOR 691

By PHYLLIS BLANCHARD, Ph.D., Philadelphia Child Guid-

ance Clinic

23 CULTURAL DETERMINANTS OF PERSONALITY 714

By GREGORY BATESON, M.A., American Museum of Natural

History, New York City

* ;

24 ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 736

By ROBERT E. L. FARIS, Ph.D., Associate Professor of Soci-

ology, Syracuse University; formerly Associate Professor

of Sociology, Bryn Mawr College

PART VI

SOME OUTSTANDING PATTERNS OF BEHAVIOR DISORDER

25 BEHAVIOR DISORDERS IN CHILDHOOD 761

By LEO KANNER, M.D., Associate Professor of Psychiatry,

Johns Hopkins Medical School; Director, Children's Psy-

chiatric Service, Johns Hopkins Hospital

iv CONTENTS

CHAPTER PAGE

26 DELINQUENT AND CRIMINAL PERSONALITIES 794

By LAWSON G. LOWREY, A.M., M.D., Editor, American

Journal of Orthopsychiatry ; Director, Brooklyn Child Guid-

ance Centre; Psychiatrist, Brooklyn Children's Service

Bureau

27 UNFIT PERSONALITIES IN THE MILITARY SERVICES . . . 822

By A. WARREN STEARNS, M.D., Dean, Tufts College Medi-

cal School (on leave); Captain, Medical Corps, United

States Naval Reserve

28 THE PSYCHONEUROSES 833

By WILLIAM MALAMUD, M.D., Professor of Psychiatry,

Tufts College Medical School and Boston University School

of Medicine; Clinical Director, Worcester State Hospital

29 THE FUNCTIONAL PSYCHOSES 861

By NORMAN CAMERON, Ph.D., M.D., Professor of Psychol-

ogy, University of Wisconsin; formerly at Phipps Psychi-

atric Clinic and Johns Hopkins University and of the

Department of Psychiatry, Cornell Medical School

30 THE CONCEPT OF PSYCHOPATHIC PERSONALITY .... 922

By PAUL WILLIAM PREU, M.D., Assistant Professor of

Psychiatry and Mental Hygiene, Yale University School

of Medicine; Physician in Charge, Psychiatric Clinic and

Associate Psychiatrist at the New Haven Hospital

31 SEIZURE STATES 938

By WILLIAM G. LENNOX, M.D., Assistant Professor of

Neurology, Harvard University Medical School; Visiting

Neurologist, Boston City Hospital

PART VII

SOME INVESTIGATED CORRELATES OF BEHAVIOR DISORDER

32 PSYCHOLOGICAL DEFICIT 971

By J. McV. HUNT, Ph.D., Associate Professor of Psychol-

ogy, Brown University; and CHARLES N. COFER, Ph.D.,

Instructor in Psychology, The George Washington Univer-

sity (on leave); Ensign, H-V(S), United States Naval

Reserve

CONTENTS v

CHAPTER PAGE

33 ELECTROS NCEPHALOGRAPHY 1033

By DONALD B. LINDSLEY, Ph.D., Assistant Professor of

Psychology, Brown University; Director of Neurophysi-

ological Laboratory and Psychology Department, The

Emma Pendleton Bradley Home

PART VIII

THERAPY AND THE PREVENTION OF BEHAVIOR DISORDERS

34 PSYCHIATRIC THERAPY 1107

By KENNETH E. APPEL, M.D., Department of Psychiatry,

University of Pennsylvania; Senior Psychiatrist, The Penn-

sylvania Hospital

35 THE PREVENTION OF PERSONALITY DISORDERS 1164

By GEORGE S. STEVENSON, M.D., Medical Director, The

National Committee for Mental Hygiene

AUTHOR INDEX 1193

SUBJECT INDEX * . . . . 1217

PART V

DETERMINANTS OF PERSONALITY-

EXPERIENTIAL AND SOCIOLOGICAL

Chapter 20

INFANTILE EXPERIENCE IN RELATION TO

PERSONALITY DEVELOPMENT

By MARGARET A. RIBBLE, M.D.

INFANTILE EXPERIENCE as an important dynamic factor in the deter-

mination of adult personality has received little attention outside the

field of psychoanalysis until recent years. The first edition of Murchi-

son's (1931) Handbook of Child Psychology carried no chapter on the

neonate, and Pratt's (1933) chapter in the second edition contains no

discussion of the effects of the newborn's experience on his later develop-

ment. The most detailed studies of infancy which we now have, those of

Gesell at Yale (see: Gesell, 1929; Gesell and Thompson, 1934; Gesell

and Amatruda, 1941) and those of C. Buhler (1930) in Vienna, deal

for the most part with the ontogenetic patterning of behavior and with

the responses which may be elicited at the various ages. We have in

American psychology no longitudinal observations concerning the effect

on the progress of this patterning of such highly personal factors as

difficulty in the organization of primary body functions, or of the influ-

ence of differing kinds of mothering which may be skilful and tender,

meager and inconsistent, or actually damaging because of fixed emo-

tional attitudes or actual neurosis in the mother.

It appears to have been the general opinion of both psychologists and

pediatricians that if an infant is properly fed and protected against cold

and infection, his abilities and personality will develop as fully as his

heredity and native endowment warrant. It seems to have been as-

sumed that his emotional and social characteristics are essentially pre-

determined by genetic control.

Yet it is reasonable enough to suppose that the sensitive organism of

the human infant would register the effects of experiences related to body

security and well-being or to insecurity and lack of personal care. 1 Once

registered, these experiences of security or insecurity would be expected

to foster responses of positive groping on the one hand, or of negative

resistance or withdrawal on the other. These early mechanisms of

1 It is known in this connection that conditioned responses can be established in

the newborn (Marquis, 1931) and that their activity cycle can be altered by varia-

tions in their feeding schedule (Marquis, 1941). (Editor)

621

622 PERSONALITY AND THE BEHAVIOR DISORDERS [20

reaction might then readily gain momentum so as to alter or even to

distort the succeeding phases of personality development.

Indeed, the establishment of the biogenetic or developmental approach

to the problems of personality makes it unnecessary to do much suppos-

ing. Our knowledge of infancy and its biopsychological significance is

growing rapidly. We know well that personality is a consequence not

only of an evolution from within but also of the effects of repeated expe-

riences through which a relationship is established with the mother and

with the immediate environment, particularly with that part of it which

satisfies the needs of life. Contributions from the fields of prenatal devel-

opment (Minkowski, 1921 ; Snyder and Rosenfeld, 1937a, 1937b, 1938),

neuroembryology (Coghill, 1929; Detweiler, 1936; Grinker, 1937, Ch.

1) have clarified our thinking about the evolution of awareness. In the

field of experimental biology, Levy (1934, 1938) and Hunt (1941) have

added further information with experimental control of the life histories

of animals. It is gradually becoming evident that the psychological care

of the infant is fully as important for his emotional, intellectual, and social

development as is careful feeding for adequate nutrition and good diges-

tive functioning.

Freud's Theory of Psychosexual Development 2

A remarkable and stimulating contribution to our conception of per-

sonality development has been made by Sigmund Freud. Through the

technique of psychoanalysis, which includes free association (see Freud,

1910; Chapter 7 by French; Chapter 6 by White), dream analysis

(Freud, 1900), and the technique of analyzing and utilizing the trans-

ference situation (Freud, 1904a, 1912), Freud was enabled to probe

deeply into the unconscious layers of the personalities of adult patients

and to reconstruct their developmental histories. A rich clinical experi-

ence in the study and treatment of neurotic individuals revealed con-

sistently that their sufferings derived from a struggle to repress or to

disguise infantile pleasure strivings connected with basic bodily functions.

Of the nature of this struggle, these neurotic individuals were unaware ;

they perceived only such superficial effects as their symptoms and their

sufferings (Breuer and Freud, 1893; Freud, 1895, 1896, and see also his

other papers of this period). Once uncovered, however, these strivings

or desires appeared closely related to the sexual perversions (Freud,

1905). They had been pushed out of awareness because they were thus

unacceptable to conscious social and personal standards ; they had been

repressed (Freud, 19l5a). The symptoms appeared to exist in these

neurotic individuals because their infantile drives had been improperly

guided in early life (Freud, 1906, 1915b, 1916). Because of either over-

2 In the interests of brevity and breadth of coverage, the editor has revised the

text of this section and added references. For any changes in emphasis or in intended

meaning, he must take the responsibility. (Editor)

20] INFANTILE EXPERIENCE 623

indulgence or excessive frustration, which had interfered with the natural

processes of maturation and sublimation, these unacceptable drives had

become intensified. Because the early conflicts remained unsolved under

conditions of stress in adult life they appeared as symptoms (Freud,

1906, 1910).

Freud's (1905) study of instinctual drives in the human being led

him to broaden the concept of sexuality to include far more than the

genital or mating activity of normal adults. In its biologically undiffer-

entiated form, he considered it as a primary creative and adaptive striv-

ing which is present in the infant at birth. Psychologically, the satisfac-

tion of these strivings connected with basic body functions is expressed

in feelings of pleasure. In this sense, sexuality contributes to the primary

orientations of the organism and to the infant's first awareness of him-

self and of his body security and of his well-being. This is the core of the

libido theory (see also Freud, 1911). A polymorphous pleasure striving

exists in every activity of the baby. Remnants of these primitive auto-

erotic pleasure strivings are found in our nightly dreams (Freud, 1900),

in our daydreaming (Freud, 1908b), and in other waking activities

which serve to free us from painful impressions. Furthermore, Freud's

(1904b) study of primitive customs, ceremonies, and myths indicated

that these also have their basis in conflict over the primitive pleasure

strivings.

In Freud's theory, libido is comparable to the appetite in the nutri-

tional system. It may be conceived as the force working within the

organism to bring about a pleasurable and satisfying state of affairs both

within itself and concerning its relation to the outside world (Freud,

1905, 1911). This pleasure striving appears to have a manifest relation

to adult sexuality after about the fourth year of life, when it blossoms

briefly into easily recognizable manifestations of what will be a mature

form of genital activity at adolescence. Both psychoanalytic findings and

direct observation of human infants indicate that these pleasure strivings

exist from the beginning of extrauterine life.

The Infantile Stages of Psychosexual Organization. In the psy-

chological development of the individual, Freud (1911) found a close

dynamic relationship between the drives of the instinctual life and higher

psychic activity. Because of this relationship, the development during

the formative years when the organism is most plastic and the processes

of maturation are most rapid is of great importance. The constant bal-

ancing and guiding of the sexual or pleasure strivings is the true aim of

both child training and therapeutic endeavor. Freud described various

mechanisms (see Chapter 7 by French and Chapter 9 by Sears) arising

from both overindulgence and repeated frustration of pleasure striving

in young children. He also described the manner in which these factors

may damage their educability and their capacity for mature and con-

trolled sex behavior after adolescence (see Freud, 191 5b, 1916, and his

many case reports).

624 PERSONALITY AND THE BEHAVIOR DISORDERS [20

During the pregenital period before about the fourth or fifth year, the

child's pleasure striving becomes organized in relation to the satisfaction

or frustration of his most prominent biological needs, and these change as

he matures (Freud, 1915b). The oral, anal, and urethral regions, where

the skin blends with the mucous membranes lining the body orifices,

are the predominant pleasure-getting (erogenous) zones of early infancy

(see also Jones, 1916a, 1916b). The skin, the general body musculature,

and the sense organs also play their role in pleasure-getting. During this

pregenital period, the child goes through three overlapping stages of

libidinal organization.

THE ORAL STAGE. The newborn infant's first and most intense

pleasure-getting derives from sucking and swallowing. At this stage

pleasure-getting is not yet separated from food ingestion. The baby

makes no distinction between incorporation and contact. In thumb-

sucking one can observe the differentiation between food ingestion and

sucking per se. It is difficult to grasp the significance of fusion and diffu-

sion in these early impulses from direct observation. The various factors

in early oral organization become evident when disturbances occur in the

orderly course of development. Later, as a consequence of maturation

and of the frustrations of weaning, pleasure in sucking and swallowing

changes to pleasure in biting, and still later to pleasure in vocalization

and speech. From the fantasies of neurotic and psychotic patients, and

from study of the customs of certain primitive races, the term cannibal-

istic has been applied to the pleasures from biting and incorporating (see

Freud, 1915b, 1915c, 1917; Abraham, 1916, 1924a). From observation

of the personality differences among primitive peoples who treat their

infants differently during this nursing stage, it appears that the effects of

this period carry over into adult behavior (Roheim, 1934; Money-Kyrle,

1939) . 3

THE ANAL STAGE. The second phase of the pregenital organization

is known as the anal sadistic stage (Freud, 1916). Very early in his life

the child appears to become aware of and to derive pleasure from expel-

ling faeces and urine. With his growing awareness in general (ego devel-

opment), the child also discerns the distaste of parents for excrement.

These observations coupled with the alternately tender and stern treat-

ment connected with his elimination tend to establish an ambivalent atti-

tude toward the parents. In this stage, too, the duality of the sexual life

is beginning to develop, but it cannot yet be designated as masculine and

feminine. It is merely relatively active or relatively passive (Freud,

3 After a survey of some of this anthropological evidence, Money-Kyrle con-

cludes as follows:

"It is impossible not to be struck by this juxtaposition of facts. Free feeding and

late weaning would seem to promote generosity and optimism. Oral deprivation

and early weaning would seem to promote stinginess and greed. To say more would

be to over-simplify the generalization." (1939, p. 126)

20] INFANTILE EXPERIENCE 625

1916). The active element is supplied by the body musculature which in

infancy may play an important role in the expulsion of faeces. The pas-

sive feeling element comes from the sensitivity of the mucous membrane

around the anus.

This expulsive phase gradually gives way to the retentive phase

wherein the child comes to get pleasure from retaining and controlling

his faeces. He usually learns that by judiciously presenting his excre-

ment like presents, he can gain attention and rewards from parents, or

by presenting them at inappropriate times, or even by smearing them, he

can cause his parents real distress. From such experience he gains a

sense of power and some appreciation of social reality. As the pressures

from social reality for sphincter control continue to increase, however,

and as the child begins to identify himself with his powerful parents and

to take over (introject) their standards, these pleasures derived from the

control of elimination for his own (narcissistic) uses are gradually relin-

quished.

Normal continuations of the anal expulsive phase manifest themselves

in the prevalent concern for daily bowel movements and in interest in

anal humor. Such plastic arts as painting are sometimes seen as sublima-

tions of tendencies fixated at the expulsive phase (Jones, 1918). For the

carry-over from fixations at the anal retentive phase, Freud (1908, 1916)

has summarized the characteristic traits as parsimony, pedantry, and

petulance (see also Abraham, 1921). The hoarding of money is some-

times seen as a sublimation of the retentive tendency (Ferenczi,

1914).

THE PHALLIC PHASE OF THE GENITAL STAGE. In the period be-

tween the second and the fourth years of life the pleasure-getting of the

child comes to be definitely related for a short time to the genital organs

(Freud, 1923b). The first aspect of this phase appears to be connected

with getting control of the urinary function which probably provides the

occasion for the child's discovery of his genitalia. Overt sexual activity

may be noticed, usually in the form of masturbation or an urge toward

physical contact with the parent of the opposite sex (Oedipus complex)

or in exhibiting the genitalia. These early genital pleasures are still self-

centered (narcissistic), but self -awareness, emotional reactions, and in-

quisitiveness especially are developing, and these can provide pleasures.

Several factors operate to bring about the repression of these early genital

strivings. Shame and disgust are actively inculcated by the parents. Cor-

poral punishment is common, and it may occur in the form of threats

to damage the genitalia (castration complex). Furthermore, with the

child's growing awareness of his own weakness in relation to the power-

fulness of his parents, he strives to be like them (identification). In this

striving, the child tends to take over (introject) the moral values of his

parents, and thus he adds guilt to the various unpleasant consequences

of his genital activities (Freud, 1923a, 1924). Gradually, as the unpleas-

626 PERSONALITY AND THE BEHAVIOR DISORDERS [20

antness and anxieties connected with these activities become greater

than the pleasures to be derived from them, the child relinquishes sexual

activities until adolescence when the maturation of the sex glands in-

creases their urgency and reactivates the infantile conflicts (see Freud,

1910).

Like the previous stages of psychosexual development, this phallic

stage has its effects on later personal characteristics. The self-centered

(narcissistic) aspect of the pleasure-getting involved is a trend likely to

continue unless the child's strivings are successfully sublimated. This

self-centeredness may appear in an unreasonable need to be loved, as

opposed to the tendency to give love and to form mutual social relation-

ships.

The Latency Period. The gradual repression of sexual activity

just described initiates what Freud called the "latency period/ 1 In this

period, the most active sublimation of pleasure striving into intellectual

curiosity and social strivings takes place. The child's patterns of self-

control are influenced by both parents, but particularly by the father (see

Freud, 1923b; also Fliigel, 1935). The impressions and standards taken

over from these first models (identification) constitute the nucleus of

what Freud has termed the super-ego, i.e., the conscience. This impor-

tant aspect of the personality is kept active by the child's love for the

parents and by fear either of losing their love or of corporal punishment

(castration) (see Freud, 1923a).

Symptoms and Anxiety. The child who has overintense or mis-

directed pleasure strivings from either overindulgence or excessive frus-

tration in infancy, is potentially neurotic. In either case he is prone to

develop pathological anxiety. Because of the weakness of the ego during

childhood, he cannot control the id strivings so strengthened, and they

are likely to break through precociously during the latency period. This

interferes with normal sublimation. Furthermore, physical immaturity

makes precocious sexual activity painful and exhausting. In consequence,

the child may regress to earlier forms of pleasure-getting, or, if his

parents will not permit these, he may develop symptoms of infantile

neurosis (Freud, 1910).

Anxiety is a phylogenetic inheritance which may be intensified. The

anxieties of early infancy, Freud (1917) believed to be due to the frus-

trations of prolonged or sudden separation from the mother (see also

Greenacre, 1942). The first example of this is birth itself. Otto Rank

(1929) has elaborated this theory. Anxiety also has intricate biological

roots connected with the protracted period of psychic helplessness and

dependency of the infant, hence, the intensification of environmental

dangers because of this inner unreadiness to make independent adjust-

ments, hence also, the overvaluation of the mother who is the natural pro-

tector against these dangers. This elemental need for love, from which

the human being never escapes, arises directly out of the factors con-

ao] INFANTILE EXPERIENCE 627

nected with the maintenance of life itself during the period of infancy.

Still another factor predisposing the human being to anxiety, Freud con-

sidered to be a tension within the organism created by sexual repression,

and this, too, he considered to be a part of man's phylogenetic inheritance

(Freud, 1926, pp. 130-132).

The general principles in Freud's theory of development are well

established. They have received confirmation from the study of primitive

peoples (Freud, 1904b; Roheim, 1934; M. Mead, 1935; Money-Kyrle,

1939). They have also received confirmation from the psychoanalytic

study of children (see A. Freud, 1928, 1937; Klein, 1932), and they

are gradually being incorporated as part of the working conception of

personality development by those outside psychoanalytic circles (see

Chapter 3 by Mowrer and Kluckhohn). These findings of Freud and his

followers suggest a new approach to the study of development in early

infancy from the standpoint of direct observation.

Evidence of the Effects of Infantile Experience on Personality

Development from Direct Observation

It has been the privilege of the writer to make clinical observations

on a large group of infants, 600 in number, for a long period of time.

These studies are not yet completed and the work has not yet been

published. 3 However, some of the findings which have a bearing on the

problem of this chapter are presented in the material which follows.

The original purpose of this study was to observe reactions in the

baby which might be related to later personality disorders. We have

watched particularly for regressive or withdrawn tendencies, for nega-

tivism, and for exaggerated reaction to frustration or to a change of

routine. We have attempted to determine whether such reactions were

present to a pathological degree at birth, or were developed as a result

of adverse experiences. Moreover, we have studied in detail how the

primary relationship of the infant to his mother is built up, and we have

examined the significance of this relationship for the development of later

emotional and social life.

Our method has consisted in the observation of sequences in the de-

velopment of the infant-mother relationship over long periods rather than

in the study of immediate reactions to any artificial situation. Our

records consist chiefly of moving pictures and of case notes. The new-

born infants were studied in three different maternity hospitals which

varied somewhat in their methods of infant care. We have also studied

infants born at home. Personality studies of a small group of cooperative

parents were made both before and after the birth of the child in an

3 This study was financed through the National Committee for Mental Hygiene

with funds granted by the Committee on Research in Dementia Praecox founded

by the Supreme Council, 33rd Degree Scottish Rite, Northern Masonic Jurisdiction,

J. S. A.

628 PERSONALITY AND THE BEHAVIOR DISORDERS [20

attempt to get some light on the "emotional environment" which might

affect the infant. So far as the mothers were concerned in this part of

our study, we investigated their childhood, their emotional satisfaction

in marriage, and their willingness to accept the feminine role as deter-

mined by their life activities, each so far as possible. With fathers, the

same general factors were investigated, and, in addition, his indirect rela-

tionship to the child through the emotional support he gave the mother

during the pregnancy and the early months of the child's life was con-

sidered.

In our studies we have given particular emphasis to the anxiety or

tensional states of the infant. We considered that these might be due to

disturbances of metabolic economy related to the rapid development of

the brain in the first months and to the inadequate distribution of the

blood stream which, in turn, is due to delay in the obliteration of the foetal

system of circulation. We took the development of awareness as our

primary object of study. We watched for evidences of security and

insecurity observed in terms of respiratory changes and of turgescence

of the skin of pleasure-getting, and of the manner in which the tactile

and kinaesthetic senses participate in the child's primary orientation and

contribute to the sense of reality. Our results indicate that all of these

are related to an innate need for contact with the mother, and that the

mother who supplies this contact unstintingly fosters her child's develop-

ment.

Characteristics of the Newborn Infant

Psychological Characteristics. Complete helplessness is the out-

standing psychological characteristic of the newborn baby. There is little

evidence of voluntary activity except that in connection with sucking

until between the second and third month following birth. During this

period, the human infant is practically a precerebrate organism, for the

forebrain is incomplete (Tilney and Kubie, 1931). Histologically, we

know that the cerebrum is incomplete, and many of the nerve tracts are

unmyelinated (Peiper, 1932; Langworthy, 1933; Conel, 1939, 1941).

The development of the forebrain during the first year of life is a tre-

mendous feat in view of the phylogenetic history of this organ. Largely

because of the undeveloped state of this organ, during this early period,

the human infant is presumably concerned only with his own inner ten-

sions of growth and development. Furthermore, brain circulation is not

yet well established (Peiper, 1928), and the capillary system is inade-

quate for its function in these first months. Even functional activities like

sucking, breathing, and eliminating are not yet well established in many

infants for some time after birth. Fifty per cent of the 600 babies in our

own study were definitely not "self-starters" in sucking. This fact, we

believe, has not been sufficiently stressed heretofore. And finally, the

persistence of a high mortality rate during this first few months of extra-

uterine life also bears witness to the newborn's helplessness and vulner-

20] INFANTILE EXPERIENCE 629

ability. All these psychological characteristics, with their organic bases,

point to the child's need for mothering.

Behavioral Characteristics. Direct observation shows that the be-

havior of the infant is periodic random activity which consists in twist-

ing, flexion and extension of the torso, kicking, arm waving, and head

turning. This "mass activity" (Coghill, 1929) is repeated at varying in-

tervals, and the rhythm is more or less individual (see also Pratt, 1933).

It begins gradually, increases in violence, and usually culminates in cry-

ing, sucking, or eliminating. It is followed by a sleeplike condition lasting

two or three hours, during which time the muscles may be tense and

small movements may frequently be seen.

These tensional states have a physiological basis, and to the writer,

they appear to be concerned with the maintenance of the circulation of

oxygen and nutritional substances to the head during the period before

the foetal channels are obliterated and the heart has definitely assumed its

postnatal function. In cases of the persistence of foetal circulatory mech-

anisms, this behavior is shown in extreme form, and it persists longer

than in the average well-organized child. Thus, this primary spontaneous

activity of the newborn apparently functions to relieve the inner tensions

connected with hunger and asphyxia by aiding circulatory distribution

of oxygen and nutritional substances. It would thus appear to be closely

related to the establishment of tissue metabolism in rapidly developing

organs, of which the brain is foremost, and it doubtless tends to produce

feelings of inner satisfaction.

Although the stimuli for this primary spontaneous activity and ten-

sion appear to be internal and very little concerned with the environment,

external conditions may influence the activity and tension considerably.

A generalized state of observable muscular tension existed and readily

became exaggerated in about 30% of the 600 newborn babies in my

study. This tension disappeared when the child sucked or when it was

put in close contact with the body of the mother. It was also relieved by

stroking the head and face, by general rhythmic movement such as rock-

ing, by a warm bath, by maintaining the child in a secure position either

by holding it in arms or by supporting it well with wrappings and pillows,

and by lowering the head and dimming the light. Such mothering defi-

nitely fosters functional integration. From my own observations I have

found that infants who do not get this sort of mothering show increasing

and persistent muscular tension, and this increasing tension is accom-

panied by inadequate breathing. Furthermore, in such cases the tension

usually persists long past the period when it may be regarded as purely

physiological. It becomes a kind of primitive anxiety.

Physiological Characteristics. The most striking and consistent

characteristic of the infant during the first three months of extrauterine

life is the tendency toward functional disorganization. Breathing is shal-

low, rapid, and frequently irregular (Brock, 1932, Vol. 2, Ch. 6). It

630 PERSONALITY AND THE BEHAVIOR DISORDERS [20

would appear that the integration between external respiration and the

tissue needs for oxygen, particularly the metabolism of the central

nervous system, becomes established gradually. The progress of this

integration may be inferred from changes in muscle tone. Furthermore,

the circulation of the child is unstable, and the gastrointestinal functions

are easily disturbed as is shown by the frequency of regurgitation,

hiccups, and diarrhea.

The organization of these physiological processes progresses gradu-

ally, probably, with the maturation of the autonomic nervous system, but

it is also clear that the progress of this organization can be affected con-

siderably by external factors. The emotionally healthy mother or nurse

can maintain balance in the body activities of the newborn child with

amazing ease unless actual disease or defect is present. But the most

trivial irregularities in the personal care and handling of any baby, such

as too little contact with the mother, too little handling, or changes of

nurses or in general routine, frequently result in such disturbances as

pallor, irregular breathing, and feeding disturbances. In infants who

are constitutionally sensitive or poorly organized, these disturbances, if

they are too frequent, may permanently alter the organic and psychic

development, and not infrequently they threaten life itself. This char-

acteristic instability, so marked in the first three months of life before

the cerebral integrative functions are in evidence and the nervous system

is more complete, continues in a lesser degree until well into the second

year when speech and locomotion are becoming established.

Direct observation thus confirms Freud's (1926) theory of the innate

predisposition of the human infant to anxiety. The infant is, by its very

incompleteness of brain and nervous system, continuously in potential

danger of functional disorganization. Outwardly the danger is that of

sudden separation from the mother who either intuitively or knowingly

must sustain this functional balance. Actual neglect or lack of love may

be equally disastrous. Inwardly the danger appears to be the mounting

of tension from biological needs and the inability of the organism to

maintain its inner energy or metabolic equilibrium and reflex excitability.

The need for oxygen may become acute because the young infant's

breathing mechanisms are not well enough developed to work adequately,

with the increasing inner demand caused by rapid forebrain develop-

ment. The need for contact with the mother is urgent in order to keep

the reflex mechanisms connected with breathing in operation as well as

to bring the sensory nervous system into functional activity. This need

to feel in the baby which is gratified best through personal stimulation is

remarkably similar to hunger for food.

Besides these dangers deriving from the possibility of interference

with the function of the organ systems themselves, the child is predis-

posed to the danger of forming strong negative emotional reactions which

later will be difficult to extinguish. At six months an inadequately

mothered infant's first dawning awareness may be that life is constantly

threatened ; at a year such a child tends to feel itself unloved.

20] INFANTILE EXPERIENCE 631

Establishing the Child's Emotional Attachment to the Mother

Much of the quality and the cohesiveness of a child's personality de-

pends upon an emotional attachment to the mother. This attachment or,

to use the psychoanalytic term, cathexis for the mother grows gradually

out of the satisfactions it derives from her. 4 We have studied the nature

of this developing attachment which is so elusive yet so essential in con-

siderable detail. Three types of sensory experience, namely, tactile,

kinaesthetic, or the sense of body position, and sound, contribute pri-

marily to its formation. The development of these sensory capacities has

been mentioned by nearly all observers of infantile behavior (Pratt,

1933), but their particular importance for the personal relation between

mother and child has not been emphasized. The sense of touch is rela-

tively acute about the head and face at birth, but it is stimulation around

the mouth that brings forth the most vigorous reactions in the small

infant. Minkowski (1921) has shown that oral sensitivity and the begin-

nings of the sucking response already are present in the foetus of three

months. The first definite evidence of satisfaction, the disappearance of

activity and muscular tension, appears in the newborn after vigorous

sucking. More than hunger satisfaction appears to be involved, for relief

of tension appears even when an insignificant amount of food, as deter-

mined in a breast-fed baby by weighing before and after nursing, has

been ingested. The sucking itself appears to be pleasurable. From the

fact that these phenomena appear during the first days of life it is clear

that the newborn infant must derive his first pleasurable orientation to

the outside world through the mouth by way of his own sucking. It is

common hospital practice to separate the infant from the mother imme-

diately after birth and to maintain this separation during the two weeks

of the lying-in period except for brief feeding or "visiting" periods. From

the observations of the writer, such early experience definitely interrupts

the formation of the child's emotional attachment for the mother and the

initial sense of security that should replace the chemical union through

the placenta. Furthermore, such early experience predisposes these sen-

sitive infants to anxiety.

The newborn child gets kinaesthetic satisfaction from being held,

moved about, and fondled by the mother. The satisfaction derived from

these forms of stimulation are registered in improved breathing, and

when observation can be made over a prolonged period, it shows in

improved digestion. Infants who do not suck vigorously seldom breathe

deeply and regularly. Those who are not held in the arms sufficiently,

particularly if they are bottle-fed babies, also develop gastro-intestinal

disorders. They become air swallowers and frequently develop what is

popularly known as colic. They may have trouble with defecation, or

they may vomit frequently. It appears that the reflex tone of the gastro-

4 For a description of this process in terms of dynamic learning theory, see

Chapter 3 by Mowrer and Kluckhohn. (Editor)

632 PERSONALITY AND THE BEHAVIOR DISORDERS [20

intestinal tract as well as of the breathing mechanism in this early period

depends in some special way upon stimulation from the periphery.

Freud has held that libidinal pleasure is involved and that libidinal

energy is distributed in these functions. Thus the touch of the mother

(or her substitute) has a definite biological implication in the regulation

of the reflexes connected with breathing and nutritive functions. 6

The sense of body position is acute in the infant at birth. It consti-

tutes a second aspect of kinaesthetic experience that is important in estab-

lishing the affective tie between mother and child. The change from a

liquid to an air environment at birth has to be compensated for gradually

by the organism. If the body of the newborn infant is not well supported

by wrappings or if the child is picked up suddenly or moved about

rapidly or violently, it reacts immediately with a startle. This innate

sensitivity, or fear of falling as it has been called (Moro, 1918),

tends normally to be overcome through gentle motion or rocking.

The old-fashioned cradle and rocking chair have considerable value in

the first months of life and they could well be returned to modern

nurseries, although the baby carriage may also supply this need.

In our follow-up study of some of these babies during the early

months, we have found that many of those who did not get this form of

mothering frequently substituted it themselves with head rolling, body

rolling, or other hyperkinetic manifestations, during periods of stress.

We found also that a large group of babies who cried persistently at

night so that they had to be walked about were cured by rocking them at

regular intervals during the day. It seems clear that the nervous system

of the infant needs some sort of "stimulus feeding" or rhythmic vibra-

tory movement to facilitate its development.

A third sensory factor which comes into this elementary child-mother

attachment is the sound of the mother's voice. The majority of newborn

babies show a violent startle-reaction to loud or sudden noises. After

the first week of life it soon becomes evident that the human voice begins

to exert a peculiarly soothing effect upon the child. We found that

mothers who make a practice of speaking softly or singing to their in-

fants while holding them have a much better relationship to the child.

The innate sensitivity to sudden loud noise appears to be counteracted

in this way. These children, as they grow older, can be soothed readily

by the mother's voice. Sensitivity to noise tends to disappear much more

rapidly from infants who are rocked and sung to judiciously at regular

intervals than in those who are left in the isolated seclusion of the

modern nursery.

It is rarely recognized, even among experts in child development, that

these early mothering activities are a vitally important factor in bringing

about nervous integration, in conserving energy for mental growth, and

in making possible the sublimation of pleasure-getting, or what Freud

5 Interesting in this connection is the story of the taming of the wolf child by

means of massage (Gesell, 1941, p. 32).

20] INFANTILE EXPERIENCE 633

has called sexual activities, in the interest of socially approved emotional

and later intellectual development. We found that emotionally disturbed

women and those who either consciously or unconsciously reject the

child are as unable to "mother" it as they are to secrete milk.

Reactions to Inadequate "Mothering." Young babies who have

not been "mothered," or those who have had adequate care and then

suddenly lose it, commonly develop one of two general types of reaction.

They may develop a form of negativistic excitement or a form of re-

gressive quiescence.

NEGATIVISM. The negativistic reaction may show itself locally in the

oral zone as a refusal to suck. With this goes what appears to be a com-

plete loss of appetite and, perhaps even more serious, a failure to assimi-

late food. Accompanying this negativistic reaction to sucking, close ob-

servation will reveal more or less hypertension or rigidity of all the body

muscles. Arms and legs resist extension. The torso is arched slightly

backward. The muscles of the back and the back of the neck are particu-

larly tense. This extensor reaction, or hypertonic reaction as it is some-

times called, is also at times accompanied by vomiting and by frequent

periods of violent screaming during which it is extremely difficult to quiet

the child. Still other common accompaniments are breath-holding, shallow

breathing, and constipation. Apparently the tension is present in both

the striped muscles and in the smooth visceral muscles.

REGRESSION. The second type of reaction to lack of or loss of mother-

ing, and to insufficient sucking activity, is a form of depressive and re-

gressive quiescence. This form of reaction has even more sinister impli-

cations than the negativistic one. When such infants are put to the

breast or given the bottle, they make a few sucking movements in re-

sponse to the stimulus situation, then quickly fall into what appears to be

sleep. This sleep has more the quality of stupor, however, for the child

does not waken for his next feeding. Frequently he can only be aroused

by repeated tickling on the soles of the feet, by shaking, by spanking,

or by being chucked under the chin. In a few babies who show especially

poor functional organization, the sucking reflex may disappear altogether

and the child has to be tube fed. Along with this oral lethargy there is a

general loss of muscle tone and reflex excitability throughout the body.

Such infants gradually develop a marked pallor and what the pediatrician

describes as skin turgor is diminished. With this condition are marked

gastro-intestinal disturbances with regurgitation of food or diarrhea.

Breathing is apt to be irregular with periods of apnoea. Hiccups and

yawning are frequent. This regressive reaction shows a marked resem-

blance to the clinical picture of shock. In the mature individual, how-

ever, shock is considered the result of overstimulation which has put the

higher nerve centers out of action. This reaction in the infant appears to

result from frustration or too little peripheral stimulation, and it appears

to consist in a tendencv of the organism to function as it did before

634 PERSONALITY AND THE BEHAVIOR DISORDERS [20

birth with a predominance of activity in the splanchnic area. Such priva-

tion appears to interfere with the blood supply to the higher centers and

thus interrupts the developmental processes through which these centers

are brought into action.

What has worked empirically in the treatment of this condition tends

to confirm our interpretation. Babies with this regressive reaction are

restored to normal, where this is possible, by supporting the peripheral

circulation with daily subcutaneous injections of saline. Body massage

and raising the foot of the bed to increase cerebral circulation are also

helpful. Artificial stimulation of the sucking reflex must be maintained

persistently for the best results. Traction on the tongue and dilatation

of the rectum may be employed in emergency, as they are for surgical

shock, to stimulate respiration.

This regressive reaction, which may develop acutely in young infants,

is strongly similar to, or is perhaps identical with, a chronic disease

known as marasmus. The name comes from a Greek word meaning

"wasting away." The affliction was well known to physicians of an

earlier time (Holt, 1918, pp. 221-226). It affects particularly children

in the first year of life, and less than three decades ago, under the name

of "debility" or "infantile atrophy," it used to be responsible for nearly

half the infant mortality rate (Holt, 1918). It was at one time thought

that this illness was due primarily to insufficient or inappropriate food,

but many of the older pediatricians connected the disease with lack of

individual care and with the institutionalization of young children. Some

related it to sudden weaning and to radical changes in routine. The

present indications are that this malady was not due primarily to in-

appropriate feeding or digestive disturbance, nor, as some investigators

have thought, to some basic biological defect of circulation. It has

instead the nature of a general disorganization of functions and a

deterioration of primary body reflexes due in large measure to lack of

"mothering" or stimulation.

These babies with marasmus develop a peculiar grayish color, as if

there were no blood in the surface of the body. Their skin lies in loose

folds over the underlying muscles which gradually lose their tone and

become flabby. The abdomen protrudes and is swollen in an exaggerated

way due to the distention of the intestines with gas and also at times

to passive congestion of the liver. We were able to study in great detail

the reactions of several marasmic infants in the nutrition ward of a large

city hospital. The experimental introduction of a "foster mother" to

give personal care and massage to these infants brought dramatic re-

sults in restoring appetite, alertness, and reflex excitability. The greater

part of the food given them, which they sometimes take quite eagerly,

goes through them with little change and is unabsorbed (Abt and Abt,

1924, pp. 263-276).

Marasmus is now becoming a rare disease, probably due to the fact

that a series of medical and social investigations have shown that an

infant, even in poor hygienic surroundings, usually thrives if it has

20] INFANTILE EXPERIENCE 635

good mothering, whereas the finest institution equipped to give the most

expert scientific care frequently could not supply the subtle personal

factor necessary to maintain healthy development. In consequence,

young infants are now kept in hospitals only for short periods when

acute illness demands it, and in cases where a baby has not suitable care

at home, it is sent to a supervised foster home.

It seems clear from these reactions that inadequate mothering is an

actual privation which may result in biological, as well as psychological,

damage to the infant's organism. It is in no sense a casual matter of

sentiment.

If we may be allowed to speculate as to the meaning of this damage,

it seems most probable that we are dealing with a defective blood supply

to the brain during the developmental shift from placental to post-natal

circulation, resulting in anoxemia or starvation to the rapidly develop-

ing nerve cells. "Physiological shock" is potential for all babies and the

prophylaxis against this or the treatment for it is consistent mothering.

Rhythmic functioning of the body reflexes and of the muscles appears to

be necessary to maintain growth in the nervous system. It would appear

that the gross extensor reaction of the body serves to bring blood or

spinal fluid into the cerebral circulation, as happens in the familiar

stretching and yawning of adults, and to maintain reflex tone. 6 The

transition from the vegetative life of the foetus to the independent and

reactive life of the infant requires a longer time in man than it does in

other mammals, and consistent mothering is required if the human infant

is to pass this transition unscarred.

Early Breathing Experiences. Because of recent indications that

mental disease may be related to deficient oxygen consumption by the

brain cells, we have made special investigations of breathing in our

infants. One of the most important findings has been that the breathing

of the neonate is precarious not only during the first days of life but up

to the time that regular vocalization begins, which is usually around the

third month. Crying during this period appears in all probability to

be a form of emergency reaction stimulated by partial suffocation. For

this reason the advice to "leave the child alone to cry it out" is dangerous

for probably the first six months of life. The crying infant needs assist-

ance with his breathing at least until vocalization is well established.

The vital importance of adequate respiratory function during this period

is its relation to the metabolism of developing brain tissue. Studies

of cerebral metabolism in the living tissue of lower animals as well as of

man indicate a tremendously high relative rate of oxygen consumption

by brain cells. "Gray matter uses more oxygen than white, and the

younger the animal, the higher the oxygen consumption of the brain"

6 The first expression of this extensor reaction is probably that which brings

about birth. It also appears in temper tantrums (see below). Peiper (1928, p. 50)

suggests that it may also be responsible for the transverse positions of the foetus

that make deliveries so difficult. He speaks of it as a "Zwangshaltung"

636 PERSONALITY AND THE BEHAVIOR DISORDERS [20

(Grinker, 1937, pp. 72-73; see also Wortis, 1941, and Peiper, 1932,

p. 115).

Ten per cent of the 600 newborn babies studied needed considerable

stimulation in order to bring their breathing activity into momentum.

The respiration of these infants during the first two weeks of life was

extremely shallow, rapid, irregular, and disturbed by every readjust-

ment. The majority of infants who did not show birth asphyxia were

also found to have unstable respiration, and such experiences as

handling by inexperienced nurses or mothers as well as no handling at

times brought about a pathological degree of irregularity.

Recent research on foetal respiration both in lower mammals and in

man has thrown some light on the reason for this breathing inadequacy.

It has been shown that definite breathing movements occur in the foetus

(Barcroft, 1936; Snyder and Rosenfeld, 1937a and 1937b). These

movements are related to the muscle of the diaphragm which in the

foetus arches high into the chest cavity over the large liver like a suction

cup. It is thought that in all probability its action is to suck oxygenated

blood toward the heart and chest generally from the region of the

placenta. After birth when air is inspired into the lungs, this action

becomes reversed. However, until the foetal circulation is obliterated

and the innervations of the diaphragm are well developed, it appears

possible for the organism to revert to the prenatal form of breathing

activity. This possibility appears to be due to the anatomical conforma-

tion of the infant's chest and the large size of the liver (Peiper, 1932,

p. 114). As a consequence of the undeveloped state of the central

nervous system, this prenatal or splanchnic orientation of the infant may

persist, and in all probability it is the biological basis for the tendency

toward regression and acute inanition. The fact that a baby can feed

and also breathe for a time from the supplies of his own liver and body

tissues may be the biological basis of these depressive processes.

We have definite chemical evidence from the study of prenatal blood

chemistry that a low margin of oxygen is present in the general circula-

tion of the foetus (Haselhorst and Stromberger, 1930). This physio-

logical anoxemia makes the birth process dangerous (see Chapter 19 by

Shock). In all probability this deepening of the oxygen privation pro-

vides the stimulus for the extensor reaction which starts birth and

assists the delivery. This extensor reaction appears as a sort of primi-

tive migratory activity, and it appears to be the first major protective

adjustment of the organism against privation. The process of birth

must further reduce the oxygen content of the infant's blood, particularly

of the cerebral supply, so that when delivery is unduly prolonged or

when anaesthesia is used freely, damage may occur to the delicate brain

cells from oxygen privation as well as from the more familiar mechan-

ical trauma.

The discovery of Snyder and Rosenfeld (1938) that the respiration

is not regulated primarily by the percentage of carbon dioxide in the

blood in either the foetus or the newborn is also of great importance

20] INFANTILE EXPERIENCE 637

in connection with the child's need for mothering. Since the newborn

infant does not get the same respiratory stimulus from this source as

does the adult, stimulus from appropriate handling is necessary in the

majority of babies to keep them breathing adequately.

Oral Experience

Modern infant culture has emphasized primarily the nutritional needs

of the infant, has limited sucking to periods of food intake, and has

largely ignored the dynamic developmental aspects and the psychological

implications of this activity. We have already mentioned the importance

of the newborn infant's first sucking activities in fostering his emotional

attachment for the mother. From my observation of 600 infants during

their stay in the lying-in hospital, of many through the first year of life,

and of a few, who received divergent forms of treatment, over a period of

five years, I am thoroughly convinced that a favorable sucking experi-

ence for the first three months contributes considerably to the develop-

ment of several aspects of structure and of behavior. The evidence

indicates that sucking experience is important for the structural develop-

ment of the face and jaws, for digestion, for the general well-being of the

child, for the development of alertness toward factors outside the child's

own body, for the age at which speech appears, and for the facility of the

speech function. Furthermore, I have found oral stimulation also closely

associated with breathing. Active sucking reflexly stimulates respi-

ration.

The importance of sucking for the structural development of the face

and jaws depends upon the role it plays in both stimulating circulation

in the oral areas and in pleasure-getting. Brock (1932, Vol. 1, p. 165),

in his summary of the biological development of the mouth cavity,

describes two structures which show erectile capacity. These are the

longitudinal swellings on the inside of the infant's lips and the so-called

magotot membrane along the lateral margin of the gums. I have been

able to see these erectile structures immediately after breast feeding in

many of the infants studied, but in bottle-fed babies they were

rarely to be seen. These structures tend to disappear after the second

or third month of extrauterine life. These findings and the fact that

babies whose sucking experience is favorable show a distinctly pleased

expression lead me to believe that sucking plays an important part in

the structural development of the face and jaws and of the sections of

the brain connected with facial expression.

Of the 600 babies I observed in maternity hospitals, 10% showed

exaggerated sucking activity at birth. They sucked their own fingers,

their lips, and their tongues. Excessive tension in the musculature of

the entire body was also usually apparent in these infants. Interference

with this sucking by tying the hands away from the mouth, which is

common hospital practice, led in the majority of cases to severe

reactions. Muscular tension increased; irregular breathing appeared,

638 PERSONALITY AND THE BEHAVIOR DISORDERS [20

and frequently periods of prolonged spasmodic crying occurred. In

others of this subgroup, the restriction of sucking was followed, after

a brief struggle, by a deep stuporous state from which the child was

aroused with difficulty for the following feedings. A more successful

way of reducing this exaggerated oral activity was to soothe the child

by gently stroking the head or by holding the infant in the arms for

short periods at regular intervals and rocking him with a gentle rhythmic

motion. These procedures reduced both the excessive sucking and the

body tension in all except a few particularly exaggerated cases. Lower-

ing the child's head at regular intervals and lowering the head of the

bed during sleep were also effective. We consider this further evidence

that cerebral anoxemia is a factor in the tension manifested in this

exaggerated sucking activity.

These procedures did not produce "spoiling" as was usually feared

by the mother or the nurse in charge. On the contrary, this soothing

care could be gradually diminished as the child's functions became

stabilized.

It was also interesting to note that these infants with exaggerated

oral drive, when assisted in this way, subsequently showed an unusual

degree of alertness. They proved precocious in the development of visual

and auditory recognition, and even later in the development of speech.

When properly handled, it appeared that this early oral drive was asso-

ciated with general alertness later.

Fifty per cent of our 600 infants had to have considerable assistance

from the nurse or mother in order to get vigorous sucking activity estab-

lished. The sucking response appeared to be either undeveloped or

inhibited in these children. If their primary sucking was not made easy

and satisfying, their sucking activities gradually diminished, and they

became either stuporous or resistive. Conditions in the mother tending to

produce this result were inverted nipples which were difficult to grasp,

unskilful holding so that apposition to the breast was not attained, and

holding the infant's head too high. Conscious or unconscious hostility

was apparently communicated to the child in some way, for a poor suck-

ing response appeared invariably in the unwanted infant. Frequent feed-

ings proved to be an efficient way of establishing a strong sucking activ-

ity in the majority of this subgroup. Frequent repetition gave the

activity the necessary momentum. With these infants it was particularly

important that the nursing periods be left completely free and uninter-

rupted. Moreover, when they were fed only every 4 hours, these babies

tended to become pathologically quiet and lethargic and had to be

awakened for feedings.

The average sucking time required during the first weeks of life for

our whole group of infants was approximately 2.5 hours of the 24.

After the first month, this average was reduced to about 2 hours. At

this latter age, 20 minutes every 3 hours was the optimum schedule for

the average healthy child, and this schedule corresponds well with feed-

20] INFANTILE EXPERIENCE 639

ing needs. Infants allowed complete freedom of sucking activity at the

breast, or bottle babies whose opportunity for sucking was supplemented

with a pacifier, rarely exceeded 2.5 hours of sucking a day after the first

month. In no baby allowed such freedom of sucking, did marked thumb-

sucking occur, except when illness interfered, or the child had insufficient

mothering of other sorts.

Favorable Effects of Unrestricted Sucking. Several physiological

functions are fostered by unrestricted sucking. The breathing of the

young infant which is characteristically shallow and irregular was defi-

nitely deepened and made more regular by satisfactory sucking experi-

ence. Well-being was increased as is shown by the fact that the first

prolonged and generalized relaxation and the first quiet and relaxed

sleep occurred after periods of unrestricted sucking. Digestion, gastro-

intestinal function, and elimination were consistently better and more

regular in babies who were allowed to suck freely at frequent inter-

vals.

Psychological functions are also fostered by unrestricted sucking.

Those babies in our group who had no difficulty with sucking and were

unrestricted focused their eyes considerably earlier on the average than

did those whose sucking was interrupted at the end of a specified time.

The unrestricted babies grasped for objects earlier. They generally

manifested a higher degree of alertness. And finally, with other factors

of mothering held equal, they began vocalizing earlier, and they began

speaking earlier. Presumably the fostering of these early developed

skills by unrestricted feeding should provide an advantage in making

later adjustments.

Effects of Restricted Sucking. Besides delaying development of

the functions just described, nursing privations produced two other types

of clearly unfortunate reactions. The first consisted of excessive rest-

lessness and periods of exaggerated crying, sometimes with general

hypertension, and sometimes with muscular rigidity and extension of

the neck. Sudden changes of routine which forced a reduction in suck-

ing activity frequently resulted in excessive thumb sucking. A few of

these infants who reacted with excitement and restlessness developed

constipation following more or less sudden limitations of sucking activity.

A second type of reaction, almost diametrically opposed to this restless-

ness, appeared in a large group of infants. In these, limiting sucking

time or prolonging the interval between meals diminished the impulse

to nurse and sometimes even produced a stuporous condition. In a few

of these infants, the sucking response disappeared completely so that

they had to be tube-fed. Such infants became generally lethargic, and

all the body muscles became lax. They frequently developed diarrhea

which in a few cases was accompanied by profuse discharges of mucous

and blood. It appears that the entire organism may be affected by suck-

ing frustration in these early months. Possibly these two types of reac-

640 PERSONALITY AND THE BEHAVIOR DISORDERS [20

tion, excessive restlessness and excessive lethargy, are prototypes of the

primary mood swings which become differentiated later in the course of

development.

Weaning. Our observations indicate that the old-fashioned practice

of weaning at some given age is unnecessary, and it is an unfortunate

procedure for the majority of infants. In this practice the individual

child's stage of development and his latent readiness for new experiences

are ignored. The individual differences in rate of development are not

sufficiently recognized, and neither are the effects of frustrating situations

on this development. We found definitely that the sucking impulse spon-

taneously wanes as new oral activities become differentiated and are

brought into momentum around the fourth month of life. Moreover,

other avenues of pleasure-getting are appearing. Vocalizing and biting

begin to supplement the primary sucking activity. The development of

hearing and seeing, as it is guided by the child's tactual contacts with

the pleasure-giving mother, enable him to be satisfied by the sound or

sight of her. When this stage has been reached with skilful handling

and with a minimum of privation of the primary mothering, the child

gives up sucking activity spontaneously, and weaning is not necessary.

When children have been frustrated in their earlier sucking and in

primary mothering, they give up sucking later and less spontaneously

(see also Levy, 1928 and 1934).

Halverson (1938) has described important experiments in which

muscle tension, air pressure, and other mechanical aspects of the sucking

response were carefully registered, and in which associations between

infantile sucking and tensional behavior were demonstrated. He does

not, however, consider the pleasure-getting aspect of sucking, nor does

he consider the relationship of sucking satisfaction to such other oral

functions as speech and to brain development. In another paper, I

(Ribble, 1939) have taken up the developmental role of sucking in con-

nection with the prenatal maturation of the tongue and its close embryo-

logical relationship to the heart and diaphragm.

Experiences Connected with Elimination

The reactions of the infant to elimination are particularly hard to

study for many obvious reasons, and the evidence available is neither so

clear nor so plentiful as that connected with oral activities. In our own

study, a few definite facts were clearly observed.

During the first four or five weeks bowel movements occur shortly

after feeding in a more or less automatic fashion. At this time, little

general reaction to faecal elimination is apparent in the child, and no

reaction to urination is apparent unless the wetting is accompanied by

chilling, or unless skin abrasions are present. After the first month or

so, however, close observation reveals such reactions to the passage of

the stool as breathing changes, reddening of the face, and changes in the

tension of the lower limbs. From an interesting study by Dennis (1932),

20] INFANTILE EXPERIENCE 641

it appears that a muscular coordination between the diaphragm and the

abdominal and anal muscles is gradually developing at about this time.

This developing coordination is soon accompanied by a tension in the

lower limbs which may be related to preparation for sitting and for

standing. This developmental stage is important in relation to breathing,

to standing and locomotion, and also to later vocalization. The first

"grunt" is, I believe, a significant aspect of the development that brings

speech. In babies who are neglected or unloved, for instance, and par-

ticularly in unmothered foundlings, the concern and excitement con-

nected with elimination appears to be exaggerated, and it is correlated

with a delay or unsteadiness in vocalization. Furthermore, breathing is

shallow in these infants. At a later stage, stimulation of the anus by

the passage of the stool may develop a tension which leads to retention

of faeces. In these unloved babies an exaggeration of anal tension almost

invariably develops, and they become constipated. In institutional prac-

tice, this constipation is usually treated with enemas and suppositories

which, as would be expected from the conditions which appear to create

this condition, only result in increasing the tendency to constipation.

Furthermore, this treatment brings these activities into the social sphere

and tends to fix the child's attention on them. In a small group of

foundlings which I studied, the difficulty with constipation disappeared

spontaneously when they were taken from the institution at an early

age and adopted into homes where they got an adequate amount of

affection and of general physical care. The "mothering" activity appears

to have been an important factor in reducing the general nervous tension

of these children, and in so doing, it removed the constipation. We have

been led to believe that such mothering is the most appropriate treat-

ment for early infantile constipation. 7

Toilet Training. Just as is true in the case of weaning, a child's

individual stage of development should be taken into consideration in

connection with toilet training. Our investigations indicate that attempt-

ing to demand cleanliness of an infant before he is able to sit alone

securely, before he has acquired at least a definite sign language, and

before he has a strong positive emotional attitude toward the mother

paves the way for later incontinence, and for later emotional and be-

havior disorders. Moreover, the functions of elimination may easily

become overerotized when early and excessive concern is shown by the

mother for eliminational regularity or cleanliness. In many babies, too

frequent diapering or insistent attempts to get the child to evacuate on

a "pottie" appeared to serve as a sort of sexual seduction, and it was

7 In this connection, a personal communication from the late Dr. Charles Stock-

ard told of thoroughbred pups which could not eliminate when they were taken from

the mother at birth so that she had no opportunity to lick them. Many valuable

dogs were lost because the keepers continued to separate pups from mothers soon

after birth and did not discover for a long time the necessity in the pup for this

"dog mothering." Thus, even in dogs mothering appears to be a factor in the tension

level and in elimination.

642 PERSONALITY AND THE BEHAVIOR DISORDERS [20

followed by evidences of excessive nervous tension which in turn appears

to have been a factor conducive to excessive masturbation. Because of

the mother's cleanliness demands, bathing and diapering form, in many

infants, a large part of the child's early social experience. Where this is

true, the subsequent desocializing of these activities is apt to constitute a

frustration quite as severe as weaning. With emotionally sound mothers

and nurses who take care to watch the behavioral signs in the children

under their care, elimination need be no problem. It can remain in a

purely physiological role.

Treating Constipation in Older Babies. In connection with direct

observation of a group of so-called "constipated babies/' we found that

the condition was relieved definitely within a period of two or three

weeks by substituting some form of pleasure or interest of a social nature

which tended to make the child feel secure and well loved. Most effec-

tive was the instituting of frequent periods of directed play in which sing-

ing or some form of motor activity appropriate for the age and indi-

viduality of the child is provided. Such play periods should also precede

feeding and sleeping in the child's routine. Allowing the constipation to

go on over a period of several days until "nature took its course" caused

no damage, but obviously this does not apply to any baby who has fever,

rash, or other evidence of physical illness. Moreover, careful observa-

tion over a fairly long period is required to determine the toilet needs

of any individual child.

We found that suppositories and cathartics resulted only in increas-

ing the tendency to difficult bowel function. The results of these pro-

cedures, particularly of repeated enemas, were not evident at once. Only

later it was observed that those children who had been subjected to

these artificial measures reacted later on, when they were disappointed

or when they felt themselves displaced by a new sibling, with constipa-

tion, incontinence, or diarrhea. These symptoms appeared clearly related

to getting maternal attention, and even punishment appeared to be pre-

ferred to no maternal concern. In particularly sensitive or seriously

frustrated children, overt smearing, dirt eating, and anal masturbation

were occasionally seen. These symptoms, and excessive nervous restless-

ness which may be developed when these symptoms are severely pun-

ished, are seen in great profusion in foundling homes. They can also be

found, however, in the sterilized, but often loveless, homes of cultured

and professional people who have no time to show consistent love and

understanding to an infant. They can best be corrected by substituting

more^ suitable forms of pleasure-getting, just as thumb-sucking is cured

by bringing the infant into a more complete emotional security.

Effects on Later Personality Development. The feelings con-

nected with elimination, and the treatment the child receives in connec-

tion with toilet training and constipation, appear particularly important

later for self-regulation and control. The triad of traits parsimony,

20] INFANTILE EXPERIENCE 643

pedantry, and petulance were consistently shown in the course of per-

sonal histories by Freud (191Sc) and it was revealed in the course of

analytic study, that such patients had had periods of mishaps in connec-

tion with bowel function recurring long past the time when this training

was supposed to be completed. Following this many sorts of unusual

behavior were said to have been noticed by parents or siblings in these

persons in connection with their elimination, and they retained a persist-

ing interest in eliminational functions. Although we have traced our

children at most for only five years, it appears that those who exhibit the

more severe anal symptoms are likely to continue to be personality

problems.

Experiences Related to Affectional Needs

By approximately the third month, in cases where no undue amount

of frustration has occurred in connection with a child's early cathexis of

the mother, the mother-child relationship takes on a distinctly new color-

ing. By this time, the organic activities of breathing, of digesting, and of

circulating blood have begun to show considerable stability, indicating

that the autonomic nervous system has taken over its specific functions.

We know from anatomical studies that the foetal system of circulation is

usually obliterated by this time (Brock, 1932, Vol. 1, Ch. 3). At about

this time, typical adult patterns of brain waves begin to appear in the

electroencephalogram (see Chapter 33 by Lindsley), and they probably

indicate a more mature form of cerebral activity. Outbursts of emotional

reaction, not always well differentiated but obviously expressing positive

or negative direction, are seen to involve the entire motor system (Gesell

and Thompson, 1934). Furthermore, and most important perhaps for

the relation between mother and child, the distance receptors have

matured to the point where they can function, and the psychological

activities have begun to develop rapidly.

With the distance receptors the child develops the ability to orientate

himself more and more through sight and sound. The eyes focus well

and can follow the mother about, the ears function well and can differ-

entiate the sounds she makes. Sound of her or sight of her produces the

positive emotional responses formerly obtained only from contact, and

consist of appropriate smiling and even genuine outbursts of joy. From

this time on actual physical contact is no longer necessary for fairly pro-

longed periods just so long as the child can hear the mother's voice or

see her while he is awake. Actual contact with the mother is necessary

at frequent intervals, however, and it is important that the child be

active in the separations which occur instead of the mother simply going

away. Frustrations of the sight and sound of mother easily produce fear-

fulness and restlessness. When the mother arbitrarily, from the child's

point of view, comes and goes about her business and social duties, or

when a continuous shifting of nurses occurs, anxiousness is the common

result. The much dreaded emotional dependency begins to develop in

644 PERSONALITY AND THE BEHAVIOR DISORDERS [20

this period. And it may appear as a response to either too much mother-

ing or too little mothering.

In this new phase of psychological development, the reactions of the

child to frustration, i.e., of not seeing or hearing the mother enough, are

considerably changed. The most conspicuous negative emotional reaction

during this phase is the temper tantrum. It appears to develop from and

to represent an exaggerated form of the extensor reaction of early

infancy. It appears to be a basic defense mechanism which is closely

related to many early aspects of developmental behavior.

Let us trace this response from its beginnings. We found this ex-

tensor reaction important in initiating the birth process where it repre-

sents a primitive postural adjustment well known to the obstetrician.

Next we found it as a reaction to frustration, i.e., inadequate sucking and

mothering, during the early weeks of extrauterine life. It has appeared

to have something to do with maintaining the internal chemical and fluid

equilibrium of the body, and perhaps with the circulation of blood, the

pressure of spinal fluid, and even with the distribution of nervous energy.

It appears normally in the yawning and stretching reaction. It is un-

doubtedly related to the opisthotonus seen in pathological conditions

where cerebral pressure is developing (meningitis, tumor of the brain, or

tuberculosis) and interfering with the blood supply to the brain. It

would appear to have survival value connected with the relief of tensions

in the head. Its danger lies, however, in the fact that it may become

the main avenue of nervous discharge, and thus assume exaggerated

importance. The results then may appear as marked interference with

sensory-motor coordination, seen first as the late appearance of co-

ordinated grasping behavior, and later as a tendency to drop objects, and

still later as a tendency to fall easily. It is highly important that this

response not be allowed to become too well established early in life.

Tantrums, like early crying, cannot be ignored until the child has gained

considerable degree of ego-development and is capable of choosing

mechanisms of expression which are to his advantage.

In the field of early emotional development we are still grossly igno-

rant. Occasions for the study of such intimate social and relational

processes are over long periods of time seldom available except in the

psychoanalysis of very young children (see A. Freud, 1937; and Klein,

1932). In the psychoanalytic transference relationship, adults frequently

relieve these reactions, and, at the present time, this is the approach from

which most of our information about the development of emotional re-

lationships comes. Direct observation lies now only in the hands of emo-

tionally free and psychologically well-oriented parents.

Animal Studies

Within the last decade two investigators have attacked the problem

of the effects of infantile nursing and feeding experiences by way of

experiments on animals. These investigators have been interested, not in

20] INFANTILE EXPERIENCE 645

generalizing the specific consequences of various kinds of infantile experi-

ences in animals to human beings, but in the general principles by which

the effects of infantile experience may be understood.

Assuming a separate need for an adequate amount of sucking, Levy

(1934) took four puppies from a litter of six and put them on con-

trolled bottle feeding. For 20 days all conditions except the time devoted

to sucking were kept as constant as possible. One pair, the "long-time-

feeders/' sucked from nipples in which the holes were small, and these

two were also given supplementary opportunities for sucking. The other

pair, the "short-time-feeders/' were fed from nipples with large holes.

In test situations these latter "short-time-feeders" showed a tendency to

prolonged sucking of all kinds of objects between meals. Levy argued

that thumb-sucking in human infants could be similarly explained by

their having had inadequate opportunities to satiate the sucking impulse.

Later Levy (1938) did a similar study with chickens. Again he assumed

a pecking instinct that would require satiation. He found that chicks

raised on wire mesh that limited the amount of pecking to a minimum

were more restless, had a lower average weight, showed more preening

behavior, more pecking at droppings and at the wall than did chicks of the

same stock which were raised under conditions similar except that the

floor of their pen was earth. An interesting additional observation was

the prevalence of feather pecking in the former. The chicks raised on the

wire floor virtually denuded their less aggressive pen mates.

Hunt (1941) has recently attempted to get controlled evidence con-

cerning whether the traces of infantile experiences actually endure to

adulthood, and to determine the importance of age at which the same

experience, quantitatively measured, occurs. Using split litters to control

heredity, he submitted halves of two litters to a controlled feeding

schedule of 15 days beginning at the twenty-fourth day of life, and

halves of another two litters to the same schedule beginning at the thirty-

second day of life. Control animals from all litters were allowed free

feeding. Then after five months during which both experimental and

control animals were allowed free feeding, he measured the amount of

food hoarded after the adult animals had been allowed only one feeding

a day for five days. The infantile frustrates in the 24-day group hoarded

approximately two and one half times as many pellets as their litter-

mate controls. The infantile frustrates in the 32-day group hoarded

approximately the same as their litter-mate controls. Thus, the traces

of the infantile experience did endure to adulthood in that group frus-

trated at the early stage. Hunt explained these results in terms of learn-

ing theory. He argued that the hunger aroused in the adult feeding

frustration served as a conditioned stimulus that set off hunger-anxiety

in those animals that had suffered sufficiently severe hunger in infancy

so that the total excitation aroused by this adult experience was greater

than that in the control animals. He argued that the traces failed to

endure in the 32-day group because, being older and better developed, the

same feeding schedule that was effective for the 24-day group was suf-

646 PERSONALITY AND THE BEHAVIOR DISORDERS [20

ficiently less severe for them so that it failed to fix the traces of the

infantile experience.

Such animal studies can be of considerable value for uncovering the

basic principles of adaptation and of the effects of infantile experience.

They are not, in our judgment, well adapted for investigation of the

detailed information that can be derived from clinical observations con-

cerning the consequences of frustrating human instinctual drives in in-

fancy on adult human personality. There are at least two reasons why

such animal studies are ill adapted for this latter purpose. First, in the

human infant the instincts are more diffuse, or less well channeled, than

they are in the lower animals. Secondly, the human capacity to generalize

its experience from one situation to others is much greater than is that

of lower animals.

General Discussion

Precise and controlled evidence as to the permanence of the effects

of these early infantile experiences in human beings is not yet available

from direct observation. In such a complicated phase of life, where physi-

ological as well as psychological factors are so deeply concerned, more

extensive observations are necessary than we have been able to make.

In general, however, it may be said that the younger the organism the

more serious and widespread is the effect of frustration. However, the

very extreme plasticity of early infancy prevents the irreversibility of

most pathological reactions, and in general, if they are recognized and

appropriately readjusted within a short enough time, no disabling damage

is done. The most important factors are the stage of development at

which the adverse experiences come and how long the widespread effects

of frustration, characteristic at an early age, are allowed to continue.

A radical change of attitude toward the instinctual life of the human

infant is necessary if overindulgence and frustration, the latter of which

is the more common, are to be avoided, and we are to substitute sound

emotional direction in their stead. The oral impulses that are implicit in

the first sucking can readily be regulated to foster better breathing, eat-

ing, and digesting during the first six months of the child's life, and to

foster the development of vocalization and good socialization during the

second six months. Toilet training should be left until body equilibrium,

sitting, and standing and adequate language responses are developed.

It is the individual child's stage of development that should serve as the

guide in these matters and not some arbitrary age.

One fact is reasonably clear, and that is that too little or inconsistent

"psychological mothering" predisposes the infant to the hazard of anxiety

and exaggerated autoerotism which may be recognized most readily in

prolonged or excessive thumb-sucking, in constipation, and in early and

excessive masturbation. Punishing these activities only increases the

anxiety, but by providing consistent and healthy emotional satisfactions

and security in the child's relationship to its parents, these practices and

20] INFANTILE EXPERIENCE 647

serious exaggeration of the primary anxiety states are avoided. More-

over, consistent security lays the foundation for the natural sublimation

of the instinctual drives in the interest of better emotional, intellectual,

social, and ethical development.

The human baby appears to have already at birth some innate tend-

ency for associating sense impressions from other sorts of personal con-

tact with the mother with his feelings of oral satisfaction. Suckling forms

the nucleus to which the concomitant stimuli of warmth and pressure are

associated, and to which the stimuli of taste, of smell, and then of sight

and of sound are still later associated. These gradually come to form an

ever-widening nucleus of awareness. Into this nucleus the early emo-

tional and social reactions of both positive and negative tendency are

integrated. In close relation to these early emotional experiences, the

concept of father and mother arise, and with them the basic interpersonal

reaction tendencies, which are so important for defining the later per-

sonality, are formed.

Our findings from direct clinical observation of babies tend to confirm

orthodox psychoanalytical theory. The pleasure got from primary body

functions appears to be an important factor in the early stabilization and

integration of the various biological activities as they are differentiated

in the course of maturation and in bringing them to full functional

capacity. The role of the mother in maintaining an orderly rhythm in

sucking, in eliminating, in general bodily movement and comfort, and in

the basic feelings of orientation and security, all of which comes from

adequate handling and fondling, is fundamental for emotional and social

development as well as for physiological control. Ruthless repression of

the pleasure-getting impulses of the baby results regularly in disorganiza-

tion and in anxiety or tensional states with the resulting formation of

such habits as thumb-sucking, persistent crying, repetitive activities,

masturbation, all of which apparently serve to relieve this anxiety or

tension to some degree.

A Few General "Psychological Rules" for Handling Young

Babies. 1. The newborn child urgently needs a long and uninterrupted

period of consistent and skilful psychological mothering, and this should

be given by a single individual where the mother herself is not available.

Such personal relationship during the early months is a necessary psycho-

logical supplement to the period of intrauterine protection. It counteracts

biological anxiety and maintains body integration while the nervous sys-

tem is maturing. It is also basic for the socialization of the child. This

first dependency relationship appears to be analogous to what the biolo-

gist calls symbiosis wherein two organisms with essentially different

needs profit by a relationship. The mother gets the satisfaction of com-

pleting the psychological creation of the child, and the infant not only

receives food and affection but gets a primary form of orientation which

helps to bring the development of the emotional, the sensory and percep-

tive processes into functional momentum.

648 PERSONALITY AND THE BEHAVIOR DISORDERS [20

2. Freedom of sucking activity is a necessity during the first months

of life. Unrestricted sucking means in no sense a lack of direction of oral

activity on the part of the parent. Instead, it means the gradual estab-

lishment of rhythmic regularity in providing for sucking, preferably in

connection with feeding, and a careful balancing and integrating with it

of other experiences like active and passive body movement, tactile expe-

rience, and ear and eye stimulation. We have found frequent, uninter-

rupted periods of feeding to be most beneficial. The intervals between

feedings should be carefully regulated to the individual needs of the child.

Such provision for sucking exercise serves definitely to prevent anxiety.

3. The transition from sucking to biting and vocalizing is a crucial

phase of personality differentiation. The growing association of mouth

grasping with hand grasping and of sensory intake through eyes and ears

with these activities leads to emotional satisfaction and fosters perceptive

capacity. During this stage of development, provision should be made for

biting ; stimulus for vocalizing should be given, and the process of grasp-

ing and carrying a cup to the mouth should be encouraged long before

withdrawal of the breast, the nursing bottle, or the pacifier is attempted.

The progression to the new and the abandonment of old forms of satis-

faction must be brought about gradually. Moreover, a parent should be

extremely tolerant of incidents where a child slips backward in the

behavioral progression in order to avoid anxiety.

4. Attempts at toilet training before the infant sits comfortably alone

and has a definite sign language with which to make known his wants

should be avoided. They predispose the child to excessive anal eroticism.

The adult should not confuse problems of laundry or individual standards

of fastidiousness with questions of biological organization. The needs of

the adult should not interfere with the child's satisfying his biological

need or with his emerging feelings of self-direction. Toilet training is a

process wherein the adult point of view should be abandoned, and the

practices of the nursery should be governed by the laws of physiological

and psychological development. Our studies show that if the small child

is well loved and secure, and is simply given the opportunity and the

time, he will automatically train himself in the control of these basic body

functions as do many of the lower animals. This comes about as a result

of the child's identifying with the wishes of a loved parent, and it is the

first sign of loving cooperation and educability in the baby. Early forced

or rigid training paves the way for disturbances in the primary integra-

tion between physiological, emotional, and locomotor activities.

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20] INFANTILE EXPERIENCE 649

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Chapter 21

CHILDHOOD EXPERIENCE IN RELATION TO

PERSONALITY DEVELOPMENT

By Lois BARCLAY MURPHY, Ph.D.

STUDIES OF CHILDREN between the ages of weaning and of adolescence

have been directed by a group of rather independent trends : * (a) inter'

est in what the child communicated verbally, which has provided the

material for work, like that of G. Stanley Hall, Stern, and Piaget, on

the child's ideas, imagination, moral attitudes, etc. ; (b) interest in the

child's behavior as observed, with varying degrees of willingness to

ask what lay back of the contacts, conflicts, approaches, nervous habits,

etc., which were being counted; 2 (c) interest in the child's emotional

development, chiefly as this has grown out of the analysis of adult

patients whose early sex experience and relationships with parents were

found to be of crucial importance for subsequent development. 3

The relation between early experience and later personality structure

has until recently been largely the concern only of this third group, the

analysts. Most of the concepts which they used have continued to come

from work upon adults, and those analysts who have worked with chil-

dren (see e.g., A. Freud, 1928, 1937, and Klein, 1937) have tended to

take their direction from this earlier work upon adults. This is certainly

not without good reason, since the child's interest in sex differences and

other experiences connected with the genitals (observation of which is

believed to be the basis for the castration complex or fear of loss of the

penis or even loss of love) and the child's intense love relation to parents

in the preschool period (which becomes involved in the "Oedipus com-

plex"), together with the prevalence of self -comfort patterns (thumb-

1 The reader who is particularly interested in the field covered by this chapter

should familiarize himself with the detailed discussion of this area in H. A. Mur-

ray's chapter "The genetical investigation of personality: childhood events" in his

Explorations in Personality. The present chapter makes no attempt to duplicate

this much more extensive presentation, but is based primarily on the bibliography

presented at the end of this chapter, research at the Sarah Lawrence College Nurs-

ery School, and unpublished records of the Institute of Child Welfare in Berkeley,

and the Cooperative School in New York.

2 I refer to studies from about 1928 to 1932 by or under the direction of D. S.

Thomas, F. L. Goodenough, W. C. Olson. Bibliographies for and a discussion of

these can be found in Murphy, Murphy, and Newcomb (1937).

3 In the last ten years, this has been supplanted by a growing body of insights

based on analytic work with children by Anna Freud, Susan Isaacs, David Levy,

E. H Erikson, and others.

652

2i ] CHILDHOOD EXPERIENCE 653

sucking and masturbation, see Levy, 1928) have not been successfully

challenged.

The time has come, however, to look at childhood experience from a

broader perspective than that which revealed these points of reference.

The Oedipus complex is primarily a way of describing one aspect of the

child's relation with his parents ; and there are many other aspects. The

relation between sibling rivalry (D. Levy, 1936b) and the Oedipus pic-

ture is now seen to be quite as important as the relations with parents.

The castration complex is one way of describing some of the small

child's feelings about his discovery of sex differences, and the things he

can relate to this discovery. The child makes many other discoveries.

The development of the Super-ego (Freud, 1923) implies many prob-

lems in the kinds of authority experienced by the child, some of which

are now being made explicit (Fromm, 1936). The Ego undoubtedly

formulates a certain direction for itself, and is caught between the

urgings of the Id, or impulse-life, and the pressure of Super-ego, or

conscience (see Chapter 3 by Mowrer and Kluckhohn) ; but what these

urgings are may differ so enormously from one child to another as to

deserve attention, and they may differ for the same child at different

points in his physical development. We can accept the basic point of

view which underlies these concepts ; that is, that the earliest authority,

love, and competitive relationships of the child to his parents, and to his

brothers and sisters, are of the greatest importance for his personality

development. But we want to look at these emotional relationships in a

wider context.

Growth and the Organism-Environment Field. Growth brings

new functions, activities, and awarenesses into the child's experience as

he moves from one developmental stage to another. Individual differ-

ences of a constitutional sort will determine areas of interest, or sus-

ceptibility to the environment, and differences in the meaning of these

growth stages, all of which need to be understood in connection with

the basic child-adult emotional patterns. Erikson (1940a), Macfarlane

(1939), and Fries and Lewi (1938), among others, have contributed

major features of this pattern.

Furthermore, both the approach developed in the writing of Gold-

stein (1939) on the organism and the field-theory of Lewin and his

associates (1939) indicate the need for more serious consideration of

child-in-total-field. An immediate illustration appears in the personality

development of three small boys, each with dominating mothers : one

defiant rebellious boy is cared for solely by the mother in a family in

which he is the only child and there are no servants. The second, a

withdrawn, pseudo-retarded boy, is being cared for by a restricting nurse,

while the mother's attention is chiefly given to her career. The third, a

disorganized, emotional, aggressive, and lovable boy, is cared for partly

by two irritable grandparents, partly by an inefficient maid, partly by the

mother whsn she is not working. The impact of a dominating mother

654 PERSONALITY AND THE BEHAVIOR DISORDERS [21

differs, depending on whether it constitutes the chief or a less important

aspect of his experience and how it is aggravated or offset by other rela-

tionships. Although it is true that in each case the boy had difficulties

in achieving a clear identification with a masculine role, the three boys

presented strikingly different personality structures. This problem of

child-in-total-field is directly related to the problem of variations in ex-

perience with the subculture and specific family group, including such

patterns as those described in this volume by Bateson (Chapter 23),

those described in Bender's (1940) discussion of children whose parents

belong to Father Divine's group, and Biihler's (1939) records of differ-

ing educational attitudes of parent toward child.

This necessity of looking at Oedipus patterns (in the sense of love

relations between parent and child) in the broadest setting and in rela-

tion to the total context of parent-child relations is implied in Champ-

ney's (1941) analysis of characteristics of the parents in the longitudinal

studies of the Pels Research Institute. The character of contact with the

child is considered in terms of intensity of contact, duration of contact,

and child-centeredness of the home. In a given instance, we may assume,

various aspects of the relation between parent and child can be seen in

relation to one another, as a step toward understanding the experience

for the child which results from the balance of various factors reinforcing

or offsetting one another. An intensely affectionate, erotically stimu-

lating mother whose emotions are centered upon her child will give him

a different experience from that which an equally intense mother with

varied outlets will give her child. Authority-love balances will differ in

meaning for the child, as they are experienced in different contexts of

great or little time with the mother, general discord or harmony in the

home, and the explicitness of love-pleasure responses to the child as

compared with those of an authoritarian character. Detailed reports on

these patterns may be expected from the Fels Research Institute.

The basic point of view which emerges from consideration of con-

temporary work on the development of the child is as follows : person-

ality development during the childhood period can be understood com-

pletely only when we consider the basic experiences of the child in rela-

tion not only to his particular parents, and to universal discoveries of sex

differences, but to his individual pattern of physical and mental growth,

the specific range of constitutional tendencies (abilities and affective

responses), and to the total field (family and neighborhood in a given

subculture) in which he is growing up. In the rest of the chapter we

shall discuss data and illustrations of specific problems within this basic

frame of reference.

Developmental Experiences Vary in Different Subcultures

The experiences of children during infancy, as at other periods, vary

strikingly with differences in the particular subculture group in which the

child is growing up. This fact has been demonstrated vividly by the

2i ] CHILDHOOD EXPERIENCE 655

analyses of personality and culture relationships in the writings of

Kardiner, DuBois, Mead, Erikson, Bateson, and the Henrys (see

Chapter 23 by Bateson). The contrast between Tennessee hill-country

families described by Claudia Lewis (1943) and those of metropolitan

areas is not limited to the contrast between the infant who is nursed for

months and the infant who is fed by the bottle method on a rigid sched-

ule. Toilet training is different when there are no toilets. The hill-

country child accompanies his mother on every sort of activity, shopping,

to funerals, and even births, at the age of two to four, while metropolitan

children are usually limited to a relatively restricted area, and generally

accompany mothers only to places like the grocery store and the parks.

The effects of these differences are not trivial. Wayne Dennis

(1940a) has, to be sure, shown that the "minimal attention" type of

handling which has some points in common with the more extremely

routinized methods of handling infants, does not inhibit the basic pattern

of maturation of motor and social skills. But I have not seen any reports

that tell us what "minimal attention" does to the child's personality. We

have seen in the preceding chapter by Dr. Ribble that the trend of

opinion from the clinical side emphasizes the need for emotional warmth

and gratification during the first year of life, as well as attention to

physical needs, if the child is to develop normally (see also Aldrich,

1939). Our longitudinal studies of children from "superior" homes in

Westchester County, New York, include several cases of severe diffi-

culties (including a type of retardation that often yields quickly to warm

attention) resulting from excessive confinement to a nursery until the age

of two or longer, and lack of affectionate contact when a child was being

raised "scientifically." David Levy's (1937) discussion of "affect-hunger"

is concerned with this problem in detail. The emphasis on the child's

need for love and gratification, as well as physical care, illustrated by

Frank's (1938) article, has provided a much-needed corrective to the

trend toward early routine training, and excessive demands for inde-

pendence.

But it may be questioned whether the present trend is not likely to

lead to overoptimism about the long-time effects of favorable experi-

ences of the first twelve months. The first experiences of frustration

may indeed sometimes traumatize the child, as "Alec" was traumatized,

so that he may never have a completely normal orientation to reality;

or the first experiences of gratification may satisfy the child so deeply

that they truly lay the foundation that determines a healthy direction for

all subsequent personality development. But studies of normal children

who are observed over a period of years indicate that the many extremely

important experiences of the next five years, including those originating

in the child himself (Shirley, 1941), may have great importance. They

may go far toward counterbalancing the ill effects of an unsatisfactory

infancy, or to undermine the first security that has resulted from satis-

fying experiences. It is hard to find in our culture as dramatic an

illustration of this as Bateson and Mead's (1942) account of Bali

656 PERSONALITY AND THE BEHAVIOR DISORDERS [21

infants who are tenderly nursed and gratified through the first months

but emotionally frustrated in the second and third years and later, with

resulting emotional indifference to personal relations as adults. The

experiences of infancy may determine to a large extent the child's ex-

pectations and the attitudes with which he approaches subsequent

experiences. Examination of our case records provides instances, how-

ever, where extreme gratification has made later frustrations harder to

accept, but more attention is being given, doubtless rightfully, to extreme

frustration during infancy which often sensitizes the child to further frus-

tration. Specific interests in bottles, or lights, or wheels, which result

from frustrations or isolated gratifications, may or may not direct the

subsequent development of interests, depending upon release opportuni-

ties which may appear during the preschool period to free the child from

a premature fixation of interest. Especially striking among our longi-

tudinal records of 90 children are several instances of pseudo-retarded

children severely deprived emotionally during infancy, very constrained as

a result, whose intelligence quotients increased by 20 to 30 points during

one to three years in nursery school (see also Kephart and Strauss,

1940; Skeels, et al, 1938; Wellman, 1940). Just as important as the

increase in IQ was the general expansion and broadening of response

to children and materials, accompanied by release from the preoccu-

pations that absorbed their attention during the constrained period. The

assumption of flexibility of personality and the possibility of release

underlies all therapy, of course. The point here is that accidental therapy

provided by changes in the environment or parents' security may operate

as effectively as planned therapy to change the total balance of childhood

experience and that the child's resilience sometimes provides its own

therapy as Shirley (1941) indicates.

Three years ago, approximately 150 nursery school teachers chiefly

from W.P.A. nursery schools sent in reports of characteristic patterns

among families in their communities, which included mill and factory

towns from the middle west, migratory camps in California, Chinese-

American communities and others. It was clear from these reports

(Murphy, 1940) that some of the incompletely Americanized groups,

such as those which were predominantly Bulgarian or Italian, were giv-

ing children more of the kind of warmth and consistent mothering which

psychiatry and pediatrics have recently come to consider desirable than

were the more completely Americanized groups (J. P. Anderson, 1940,

Baruch, 1937). The unspoiled maternal attitude has much to counteract,

however, when it confronts the instability of depression years for chil-

dren migrating from the Dust-bowl to tents in California where "we

ain't got nothing for keeps," or sudden changes of the Defense areas,

which move families unexpectedly out of their village life. Changes

of longer trend are also bringing into existence new configurations of

child-adult relationships, as the proportion of children to adults changes

and the number of old people increases. In the various subculture

2i ] CHILDHOOD EXPERIENCE 657

groups, we find then different combinations of gratification and frus-

tration; a satisfying infancy does not necessarily compensate for eco-

nomic deprivation in the next ten years, and there is increasing evidence

that later gratification may go far toward offsetting the effects of early

frustration.

Maturation and the Socialization of New Functions in the

Preschool Period

The appearance of walking and talking brings a period of active

socialization for nearly all middle-class children. In families where prop-

erty is particularly important, manipulatory activities, exploration, keep-

ing out of dirt, and not messing around may be major issues (Lerner

and Murphy, 1941). An impressionable child may recoil from manipu-

lating things and become inhibited in manual activities as a result of this

training ; or he may become so preoccupied with orderliness that he does

not play freely with toys. If he is more spirited and stubborn, he may

persist in handling things his own way ; or he may learn when, where,

and how to handle things. The patterns of inhibition or spontaneity

developed in this way are reflected in the structures that are created in

his handling of toys and plastics. The anxiety which arises from exces-

sive constraint or guilt about manipulation both of objects and of himself,

may become generalized so that it is also expressed in social attitudes

and in bodily posture. Our records also show instances where a general

anxiety acts as a general inhibitor on both manipulatory and locomotor

activities, and sometimes speech as well.

Locomotion that is, walking, climbing, jumping, sliding, and all

other leg-activities that become possible when coordination of legs im-

proves may have similar possibilities ; encouragement may lead to the

development of security in getting around the world of space and

objects; interference, anxiety, or punishment from adults for locomoting

into, onto, down from, or up on the wrong places, may block the use and

enjoyment of new coordinations. Or these frustrations may lead to com-

pulsive concern with substitute activities such as unhooking, unscrew-

ing, unlocking, i.e., opening the closed or forbidden places. Children in

apartments are very often exposed to a great deal of inhibition of loco-

motion; if you dance, jump, hop, or skip, the neighbors on the floor

below may protest. When compensatory outlets are afforded by all-day

nursery schools or playgrounds, the child may be able to structure his

activity in terms of areas of freedom and areas of control. But without

such compensatory outlets he may become inhibited, or confused and

anxious about motor activity.

Even language, which does not damage property, may become a source

of new rapport with adults who are delighted with the increasing com-'

panionship that comes with the child's ability to communicate his

thoughts* or it may have a nuisance-value for the parent who is irri-

658 PERSONALITY AND THE BEHAVIOR DISORDERS [21

tated by two- and three-year-old chatter. We have instances of children

who, blocked by adult restraint of manipulation or locomotion, com-

pulsively use language as a substitute.

Manipulation, locomotion, and language are then three obvious devel-

opmental experiences which, because of what they stimulate the child to

do, and how they are treated in the child's family and broader culture-

group, acquire valences and meanings which become deeply embedded in

the child's personality.

Interaction of Mother's Personality with Growth-Needs of the

Young Child. As these and other new capacities emerge, our records

indicate that the influence of the mother and others in the family largely

determine what these new capacities for experience will mean to the

child, what new securities they may bring, and what new threats they

may present. Probably no family succeeds in making maximal use of

each developmental stage for the child's personality development. In

infancy, the protective mother may give the child a great deal of satis-

faction if she is the kind who is protective because she is fond of babies

and gets a great deal of satisfaction from them. But at the stage of ex-

panding locomotion and exploration, the overprotective mother becomes

an inhibitor and deprives the child of opportunities which he needs to

use his new abilities (see also Levy, 1939a). This deprivation may be

even more disturbing to the child who has earlier been handled per-

missively than to the child who has made some kind of adjustment to

early deprivations.

The excessively scientific mother, or rejecting mother, or other type

of mother who deprives the child of emotional satisfaction at the infancy

level, may by contrast give the child more approval and emotional satis-

faction at the locomotor period, because she is pleased by the new signs

of independence. This may be releasing to the child, or he may over-

react so that he becomes compulsive about the new activities which gain

so much approval; this may then lead to a kind of forced spontaneity

or exploratory activity which we see not uncommonly among children

from homes which give little affection and much encouragement to motor

activity.

On the other hand, mothers who are unable to accept the child's in-

creasing explorativeness, may virtually imprison him, keeping him "out

of the way" or "safe" in crib, playpen, playroom, or fenced-in yard, so

as to minimize his nuisance-value, and thus add this deprivation of the

exploratory stage to the basic emotional deprivation of the earlier stages.

Or the child may not feel deprived, but may accept the place-confinement

with subsequent fear of new places and dependence upon some definite

home-base.

The experience which the child has at each new stage depends then

partly on how this new stage is interpreted and accepted by those who

surround him, and the values they place upon it. The values of individual

mothers even in a limited culture-area may vary considerably. Dan's

2i] CHILDHOOD EXPERIENCE 659

mother accepts boisterous activity, but not dirt] her son remarked,

"There isn't any place to dig in my garden, there isn't any place for

myself." Another mother accepts boisterousness and dirt but gets ex-

plosive when things are broken. Another mother does not mind any

consequences of vigorous exploratory activity, but gets very anxious

when the child regresses to earlier phases, such as thumb-sucking or bed-

wetting. In each case the mother has some criterion for success; she

feels successful when her child is clean, or well-behaved, or has good

habits ; she feels that she is a failure when he is not. 4

This discussion of universal experiences of growth in the early pre-

school period has illustrated the variations in the meaning of these experi-

ences to the child, as these variations are related to parental handling

and attitudes toward these growth experiences. Parental handling and

attitudes cannot be completely separated from the question of individual

differences in the original values of locomotion, manipulation, and

language to the child himself.

The child with more active sensory interests and less skilful coordina-

tion, described by Shirley (1939), may often be more responsive to

sensory stimuli and less interested in social experiences or in experi-

ences involving skilled coordination. If, as in the case of several chil-

dren in the writer's social behavior study (Murphy, 1937), the child

wants music, dancing, or the enjoyment of fascinating objects like cars,

for the sake of the enjoyment, not for the sake of constructive activity,

his experience will vary with the mother's or teacher's willingness to

encourage, or compulsion to frustrate, the child's preferred response. In

our culture, children whose own interests lead them to longer periods

of appreciation rather than to "constructive" activity are less likely to

receive approval than those who build with blocks, and ride tricycles

early. In some groups construction is virtually a criterion of good

adjustment.

Authority Patterns Experienced by the Child

Variations in the methods of exercising authority must be seen in

relation to the total pattern of the parents' personalities and of the home

life, as well as variations in the children's sensitivity to different kinds

of treatment. Regardless of the mother's concern and the mother's

interests, and regardless of particular patterns of child-adult companion-

ships in any community, the methods of enforcing authority and atti-

tudes with which socialization is done are also of importance for the

child's personality (Fromm, 1934). Fromm-Reichmann (1940) and

4 Oddly enough, recent reports on the Sioux (Erikson, 1939), the Hopi (Dennis,

1940b), the Navaho (Kluckhohn, 1942), and other Indian groups in this country

are giving us a more complete conception of the rearing of infants and young chil-

dren in these cultures than we have for a comparable variety of white or of Negro

children. We actually know rather little about the variations in gratification, frus-

tration balance, or the specific experiences of preschool children outside of a few

university centers.

660 PERSONALITY AND THE BEHAVIOR DISORDERS [21

others point out that in this country the processes of socialization and

personality development of the child are complicated by the fact that

both discipline and love are to so large a degree centered in the mother,

in contrast to the European pattern of family life where the father has

been predominantly the giver of discipline, and the mother the giver of

love. Where this is true, it must affect the development of identification

with the parents, though it must result in a somewhat different form of

the Oedipus pattern, since the daughter is confronted with the necessity

to identify with the person who is frustrating her as well as loving her,

and the son may not feel the father as "strong" since he does not figure

so vigorously in discipline situations, and may therefore sometimes find

it difficult to switch his identification from mother to father (see also

Mowrer and Kluckhohn, Chapter 3).

Related to this is the problem of the balance of love, protection, and

attention with discipline and control. The literature (see Symonds,

1939) is full of admonitions to mothers to avoid the pitfalls of over-

protecting, overloving, underloving, overdisciplining and giving too little

discipline, giving too little attention and companionship or too much,

identifying too closely or too little with the child. With all of the dis-

cussion of these pitfalls and their undesirable results, there is little

recognition of the relative rather than the absolute nature of these

excesses and deficiencies. Each mother is herself, and has not been

selected by any omniscient agency as parent to her particular child.

What is overprotection for one child is underprotection for another;

an amount of affection which fails to satisfy one child's craving stifles

another; an amount and kind of discipline that is inconsequential for

one child is very inhibiting to a more timid one. In an unpublished study,

Anna Hartoch points out that the child's longings, capacities to resist,

to accept, to evade, to build his own world for himself will to a large

extent determine what a given parent's balance of love, discipline, atten-

tion, and protection will do to him or for him.

Whatever these experiences have been, of being loved, disciplined,

protected, and attended to (too little or too much for him) they become

deeply a part of his affective and mental development, so that his

behavior, the words he uses (Despert, 1938a, 1940), the games he

makes up (Lowenfield, 1939), the way he responds to a Rorschach

test (Amen, 1940), or to free play with miniature toys (Erikson,

1940b), and a host of other everyday behavior, betray these experiences,

the way in which they have furnished his life-space, and the balance of

inhibition and spontaneous satisfaction which they permit him (Lerner

and Murphy, 1941).

The Child's Life-Space. These authority-love relations with his

parents are, however, only a part of the picture ; the environment they

create for him, the rhythm of life which emerges from the pattern of

their activities, also shapes his life-space and is assimilated into the

.structure of his personality. The home which is rigidly organized and

21] CHILDHOOD EXPERIENCE 661

proper, the home which is chaotic, the home which has certain areas

of clear organization with other areas of freedom, the home which is

specially concerned with eating or sleeping, or with new furnishings

end decorations, or with much company coming and going each of

these has been spontaneously depicted by a three- or four-year-old child

who has been given the opportunity to describe his life-space in free

play with toys, without knowing that this is what he is doing (Lerner

and Murphy, 1941). The way in which he organizes objects, however,

is not the only record of this home experience; his organization of

objects is often related to his pattern of inhibitions or freedom of bodily

movements, conversation, and emotional expression. What he does with

paint is not independent, unrelated to his play with toys, or with other

children, but usually reflects the same underlying attitudes of freedom

to experience new situations, a need to create a protective structure

before he can be free, or a need to compensate for pressures and re-

straints against which he rebels (Schmidl-Waehner, 1943). These

illustrations describe only a few of the possible patterns which observa-

tion of the child's expression will give; the specific structure and con-

tent of any child's expression will be his own.

Eating, and washing, and going to bed makes a routine pattern which

seems to form the basis of one child's life, which he contrasts with the

spontaneity of animals in the woods; another organizes life within the

house in a mechanical way, but carries on outside of the home exciting

activities such as boat and train rides, horse and dog shows, which

correspond accurately to the pattern of his own life. These experiences

of fun, excitement, and participation contribute to the whole texture of

life as the young child experiences it, and form the backdrop against

which experiences of discipline or deprivation or love seem more or less

important. A family that is in many ways rigid and overcontrolled may

stimulate spontaneity in a child by having an active dog or kitten in the

house ; or by allowing freedom for play with neighborhood children ; or

by providing experience at a releasing nursery school. The total balance

of hours spent and satisfaction gained on the side of release as compared

with the inhibition side may determine not only the thematic content

of the child's consciousness, but whether or not he needs to rely on

actions of obstinacy, overcompliance, or evasive detachment, and whether

he carries along anxiety and irritation regarding authority and the

grownups. If his experience with parents has been satisfactory, the

identification with them which results may, according to Zucker (1943),

be one of the most important deterrents to delinquent behavior.

Individual Susceptibilities in Response to Social Experience

We must now return to the question of the individual way in which

each child experiences the events and attitudes to which he is exposed.

Burgum's recent article (1940) on some positive results of rejection

must imply just what we have been saying : that a given experience will

662 PERSONALITY AND THE BEHAVIOR DISORDERS [21

mean different things to different children depending on the child's

needs and resources. The children who showed severe personality reac-

tions to experiences of emotional malnutrition in our studies were by no

means children from families which were unique. They came from fam-

ilies that were not spontaneous and warm, to be sure ; but their families

in all likelihood would be no more lacking emotionally than those of a

number of other children who had survived without showing neurotic

or prepsychotic signs of any sort. Similarly, children who show strong

resistance to authority are not merely those who have had excessive

authority. Discipline which rolls off the back of one child will keep

another child awake at night. This seems obvious enough when put this

way, but it is often left out of account when discussing parental patterns

in relation to the experience of the child. Often we discuss the child's

behavior in terms of what the parent has done and fail to ask what the

child was like to start with and how his sensitivities and resources have

affected his response to the parent. Reports of the mature personalities

of twins reared apart under grossly differing conditions, such as extreme

rejection for one twin and great security for the other, indicate how

powerful the inherent pattern of personality development is (Burks,

1942). Only slightly less startling are the data on differences in the

personality structure of twins reared together (Troup, 1938; see also

Chapter 16 by Penrose).

What are some of the possible innate factors that may affect a child's

response to the amount of love and discipline that he gets ? An infant's

satisfaction in contact and cuddling or social experiences (Washburn,

1929) is one item ; the thresholds of one child are lower for these experi-

ences than are those of another child. A child's sensitivity to sounds,

loud noises, and to physical pain will play a part in determining how

painful the scoldings and spankings actually are. His thresholds for

reactions to sudden experiences, to changes in atmosphere, will also be

important in relation to his response to the variability of a parent's

mood.

Or we may take, as another example, comparable situations of family

structure, which again point up how the child selects from the situation

what he will react to and make use of, thereby creating his experi-

ence. In a pair of families there are two active parents in each case,

with an active and vigorous older brother and a younger sister. In one

case the sister is an artistic, independent youngster who does not identify

with the rest of the family intensely, but has built up a sturdy world of

her own. In the other case the younger sister "insists on her rights"

and tries to keep up with older brother at every point. More consistently

included ia the group of older members of the family, she has probably

more conflict about her role than the other sister who has accepted a

more independent relation to the family, although she is more isolated.

When we look at older sisters with young brother, we find different

relations also, depending on the resources of the two children, their

energy and growth patterns. One older sister is dominant, preferred,

ai] CHILDHOOD EXPERIENCE 663

secure, indifferent to her younger brother. Another feels dispossessed,

unable to cope with the greater energy, physical vigor, even size of her

younger brother, and retreats into a shell. It is doubtless because of

these many variations, obvious or subtle, in the capacities and feelings

of children that it has been so hard to get a clear formula for the per-

sonality consequences of a given sibling constellation. In a broad

statistical sense there probably are some character-trends associated with

family position (Murphy, Murphy, and Newcomb, 1937, pp. 348-363),

but the trends are often overwhelmed by individual factors. The child

chooses, not consciously, but nevertheless significantly, what his particu-

lar family constellation is going to do to him, and of course we may add,

what he is going to do to it.

The discussion so far has repeatedly implied that constitutional dif-

ferences in the child must be taken into account in evaluating the actual

experience which results from exposure to any pattern of parent atti-

tudes or handling, or indeed any pattern offered by the culture at all.

These differences include not only the measured and recorded differ-

ences of physical dimensions, of performance on intelligence tests, and

of sensory and motor functions such as pitch discrimination and mus-

cular strength ; they include the thousands of other differences, such as

those of sensitivity to pain, of response to color, to sound, of readiness

for motor or manual coordinations, which are familiar to teachers ac-

quainted with many children. Psychiatrists, well aware of the condi-

tioning influences of all parental attitudes, have been inclined to put the

burden of proof on the person who pointed out possible innate differ-

ences as responsible for such difficulties as inability to spell, do arith-

metic, draw, or act. They found it easy to point to cogent evidence that

Mary T. obviously had reading difficulties because of her emotional

tension over her sister's superiority; and that Billy D. had been put

under so much pressure from his father that his difficulties were largely

due to resistance to his father's authority pattern. This type of thinking

has contributed a great deal to our understanding of a child's develop-

ment in so far as emotional conflicts actually are responsible for specific

competences or difficulties. But it has also helped to postpone the day

when we would arrive at a more complete picture of the two-way passage

of interaction between child and parent which underlies the child's

personality as we see it. Horace English some years ago (1929) pointed

out that even such an obvious hypothesis as Watson's statement about

loud sounds as a cause of fear needed to be revised with some attention

to individual differences. He cited the behavior of a small girl who, sit-

ting in a high chair, heard the violent sound of a two-pound hammer

striking an iron spring behind her chair, without giving any evidence

of fear at all. Jean Macfarlane (1939), with a background of both

clinical experience and training in experimental psychology, has been

following the evidences of consistent patterns of adjustment of infants

and children. Her data suggest that instead of confining our notions of

variability in human beings to whatever cortical functions underlie dif-

664 PERSONALITY AND THE BEHAVIOR DISORDERS [21

ferences as they are measured in studies of intelligence and physique,

we might better think of each infant as an individual organism with its

own pattern of thresholds or readiness for stimulation or responsiveness.

R. W. Washburn's early reports (1929) of striking individual differ-

ences in readiness for laughter, and the more recently published reports

of Gesell and his associates (1940) noting important differences in per-

ceptiveness or awareness of infants, as well as the differences in per-

ceptual and manipulative abilities, contribute further support to this

approach. Shirley's (1939) study of about 200 premature children indi-

cates that these children show greater responsiveness to sensory stimuli,

such as colors, sounds, tones, textures ; greater emotional responsiveness ;

but less skilful motor coordinations. These factors may combine to give

a "syndrome" of "sensitiveness" which makes the personality develop-

ment of these children similar despite their genetic differences.

Margaret Fries, who has been especially interested in the way in

which infants respond to frustration rather than in the skills studied by

Gesell or the patterns of responsiveness noted by Shirley, observes (Fries

and Lewi, 1938) that among the children she has watched from birth,

clear differences may be seen between those who adjust to frustration

in passive ways and those who are more active (see also Ribble, Chapter

20, who notes these reaction types in the newborn). It would be inter-

esting to relate these differences both to the pattern of abilities and to the

interests of the child, especially in the light of those differences in sensory

and motor skills or responsiveness which Shirley discussed. This differ-

ence in activity-level in response to frustration may be related to the

difference between infants who show overt as compared with internal

evidences of emotional response as described by H. E. Jones (1935).

But we do not yet have a study which combines behavior observation,

physiological measures and the equivalent of a Rorschach for infants,

to show us the relation between these differences and their meaning for

the personality structure of individual children. (In this connection,

recall also the "inhibited" and "excited" dogs of Pavlov ; see Chapter 12

by Liddell.)

Macfarlane (1939) summarizes her own analyses of longitudinal

studies of several hundred children in terms which integrate all of the

findings referred to above. She sees the individual child as sharing com-

mon needs, response patterns, and susceptibility to stimulation with other

children; but he also possesses individual characteristics "which make

for differing susceptibilities to stimulation, differing needs and differing

response patterns." She comments :

Whether these differences are in large part a function of heredity

and maturational processes, or in large part a function of modification

of basic structure by health, special experiences or differing environ-

mental pressures and assaults, they exist and must be inspected along

with common structure in terms of their meaning to the adjustive

process. . . . Differences exist in morphology, size and rate of

growth, muscular equipment, nervous reactivity, sensory acuity,

21] CHILDHOOD EXPERIENCE 665

energy level, achievements, tensional states (directly organic, and pro-

duced by conflicting reaction patterns). Not only are there specific

differences, but differences in configurations of equipment occur

which have differing influences both upon susceptibility to stimulation

and upon response patternings. The child who is at either end of the

distribution curve has not only different organic stresses to contend

with than the child in the middle of the distribution a fact which

may influence behavior appreciably but he may also develop totally

different attitudes and reactions toward himself through continuous

comparisons with the group. And additionally, because certain

behavior is precluded or fostered for him by these facts of equip-

ment, he may receive differential treatment by the social environment

and an even larger discrepancy in behavior may appear than these

structural differences (in and of themselves) would produce. (1939,

pp. 4-5)

Constitutional differences are at least indirectly involved also in differ-

ences between three four-year-old boys who use aggressive behavior in

different situations: one is aggressive only when blocked or frustrated

or interfered with ; another is aggressive when he is afraid ; another is

aggressive as a way of enhancing his sense of bigness.

Probably innate differences in sensitivity to form and structure are

important in contributing to one child's extreme sensitiveness to adult

patterns (with resulting strong Super-ego development), while another

child faced with similar standards but possessing less sensitivity to form

is not so strict with himself (see Sheldon, Chapter 17). Differences in

the extent to which individual children resort to thumb-sucking and

masturbation are not only the result of the amount of frustration or need

for comfort, but are related to the strength of these satisfactions in com-

parison with others.

Growth Spurts Create Sensitivities. Erikson's analysis (1940a)

of the importance of growth nodes for experience thresholds is impor-

tant both for groups and for individual children. He emphasized the

importance of "proper rate" and "normal sequence" of development in

the successive manifestations of personality, on the analogy of the pattern

of sequences which must take place in its preordained order if the embryo

is to emerge with normal equipment for physiological functioning. Each

new phase of post-natal development brings its own opportunities for

satisfaction in functioning, and its own need for adequate satisfaction at

each level. Interruption of sucking, manipulation, motor activity, or

speech may not only have important consequences for this function but

for a wide range of personality and behavior traits related to it. Traumas

during early childhood are likely to find a response at that point which,

through recency of maturation, is most vulnerable, and most easily apt

to become disorganized. Thus, a child who has been walking six or eight

months with considerable security but only recently talking, will not be

so likely to show disturbance of general motor coordination as of speech,

666 PERSONALITY AND THE BEHAVIOR DISORDERS [21

if shocked by a traumatic experience at that point. Here again, we may

say that the point of lowest thresholds will determine the way in which

a given external event will be experienced by the child.

The child's experiences of his own growth pattern may also be inten-

sified when spurts of growth do not coincide with those of most of his

friends: unpublished records from the Jones longitudinal studies of

children from ten to sixteen at Berkeley include instances of children

who gain additional security from the consciousness of early physical

maturing, and also records of other children who, though secure in

leadership at ten, become unhappy when other children spurt ahead of

them, or when others develop masculine and feminine interests of

adolescence for which they themselves are not ready.

The Child's Experience of Self

The child's own sense of himself, or experience of self-hood, probably

overlaps only partially with the self that we ascribe to him when we

make a complete inventory of the characteristics of his individuality. For

his experience of self is built partly out of the reactions of other people

to his individuality : what his height-weight ratio means to them in rela-

tion to that of other children, or their ideal, or his parents' expectations.

Partly it is built out of his own comparisons of himself with others. The

child, as Schilder (1935) points out, perceives his own movements with

an experience of ease and pleasure or of effort, and also has the experi-

ence of keeping up, or not keeping up, with the movements of others.

He experiences his face as one which evokes smiles, or withdrawal, or

sympathy from others; he also experiences it, sooner or later, as one

which "doesn't fit my personality" as one nine-year-old would-be box-

ing expert commented or one which does fit, or is his personality. So

with his abilities: intelligence, talents, capacities for social communica-

tion, leadership, and simple things like size and strength. Defects and

diseases not only produce physical sequelae which are important for the

personality as seen by others; they produce patterns of desire, will,

aspiration-levels, and estimations of self that make up the child's feeling

of himself. The vigorous, spastic child described by Gesell (1939), who

succeeded in getting his friends to help him through a tunnel in which

they had been crawling, had a different conception of self from that of a

more passive child.

This process of self-evaluation is not dependent solely upon social re-

sponses to the physical differences we have discussed. It may be subtly

bound up with the child's affective responses to the external world. Thus

a child who is small and who also has a tendency to perceive and enjoy

and use fine detail may find in himself a likeness to those objective qual-

ities in the outside world which are satisfying. Such a child may be less

likely to show marked compensatory behavior directed at overcoming

his experience of small size than a child of the same build whose affec-

2i ] CHILDHOOD EXPERIENCE 667

live and perceptual patterns are the reverse. If a child who is small

enjoys larger units in the objective world, and the activity that goes with

them, he may be stimulated to attempt them even though his size places

him at a disadvantage. Thus we see small individuals whose whole life

seems dominated by a quality of fine or dainty or detailed activity which

appears to be both a part of themselves and a response to the external

world. Similarly we may find large children whose whole life is an ex-

pression of largeness, being large, responding to large activities, and

enjoying it, while others are uncomfortable with their size because their

perceptual-affective responses ask for different values. Another example

is that of the child whose sensitivity to tactual and texture experiences

leads her to enjoy soft materials and objects, and who may identify her

own soft hair, skin, dresses with this pleasant experience, while another

child with the same perceptual and affective responses does not find these

satisfactions in herself. Patterns of self-loving, or of dependence upon

the outside world, or of conflict between inner and outer values may be

rooted in this type of experience, as Schilder (1939) has suggested,

granted that socialization processes augment or frustrate the spontaneous

pattern.

Macfarlane (1939) summarizes the social aspects of the child's ad-

just ive pattern and of the value he places upon himself, with the illustra-

tion of the small boy whose experience will differ, depending upon

whether his father was a football hero and expects his son to be one,

or a college professor with a desire that his son follow that tradition.

Similarly, she observes, this boy has a very different adjustive picture

if his brothers are larger and more athletic than he has if they are like

himself. "His size, then, takes on meaning in terms of (1) the other

aspects of his structural equipment; (2) in terms of the size of people

with whom he is closely associated; (3) in terms of family and social

expectancies and values connected with size or achievement dependent

on size . . .; (4) in terms of the adequacy of other family and social

supports; and (5) in terms of the success of direct or compensatory

achievements which do not depend on size." In addition, "His vulner-

ability may vary in a fast-growing or slow-growing period because of

physiological changes, or new adjustments to learn ... or because of

new attitudes and pressures from outside to which he must adjust"

(p. 5).

Up to this point we have tried to illustrate in different ways the gen-

eral principle that the young child's experience, and the personality it

produces, varies both with the particular events, attitudes, patterns of

objects, and people to which he is exposed, and with the pattern of

thresholds for response to, or needs for, different types of stimulation

inherent in both the relatively stable and the rapidly changing aspects of

his own organic structure at the time the experience occurs. (For some

behavioral correlates of various types of structure, see Chapter 17 by

Sheldon.)

668 PERSONALITY AND THE BEHAVIOR DISORDERS [21

Changing Status in Early Childhood

All children are exposed to the shifting attitudes of parents, of siblings,

and of other persons in immediate contact with the child attitudes

which shift as the changing behavior, appearance, interests, and activities

of the growing child fit into or conflict with the parents' style of life,

or image of what is desirable in a child. Most children show some

periods when they are either an ego-asset or an ego-hazard to their

parents. If, as an infant, the child is beautiful, brilliant, cute, or in other

ways fulfils the parents' expectations of what a baby should be, he obtains

rapport easily. If he appears ugly, or possessed of the undesirable traits

of "the other side of the family/' or seems dull, or unresponsive, the

parent may be frustrated and cannot help but give the child a different

response: either compensatory pity, defensive love, or unconscious or

conscious coolness or rejection. If the child changes as he grows, and

becomes definitely more, or definitely less, beautiful, well-behaved, physi-

cally adequate, or conforming to the conventional pattern for his age, the

parents' attitudes may change, depending on how fluid the parents' own

attitudes are. In particular, if an originally "good" child becomes, in

response to frustrations too great for him to deal with easily, a "bad"

child, the parents' irritation and anxiety are likely to add to the frustra-

tion and set up a circle which is hard to penetrate. However, neither

painful treatment nor excessive attention from adults brings a uniform

response from every child; one child may develop a protective wall or

mask to defend himself against the very attention that another child

has come to crave. In each case, however, the interactions with people

have contributed to the personality structure of the child, the narcistic

wounds or ego-inflation, and his defenses against further hurt or his

expectations of further adulation.

Nursery School Experience. Experiences in nursery school are

also different for different children. Some children, frustrated in non-

child-oriented homes and inhibited by their experience, may respond

quickly to the permissive and warm atmosphere of a good nursery school.

The mother discovers that the child who "never smiled" and who seemed

unappealing has now become lovable, and is herself warmed into respon-

siveness. The reverse, unfortunately, may also happen. A child who has

grown up in a protected home, where he has been gay and serene in the

warm atmosphere of parental affection, goes to nursery school, and may

find himself bewildered by the presence of many children who seem to

be competitors. Such previous experience is unlikely to give him tech-

niques for dealing with the combination of aggressive, exploratory, play-

ful overtures which he may receive from other children.

Reports from many groups make clear the great amount of conflict

which the nursery school child experiences, although this varies with the

space, equipment, and age-range of the children in different groups, as

well as with the authority patterns of teachers (Fite. 1940; Murphy,

2i ] CHILDHOOD EXPERIENCE 669

1937; Jersild and Markey, 1937; Roff and Roff, 1940). Protection from

and cooperation with others of one's own age are other aspects of partici-

pation in a large group, and this rich experience may bring dramatic

changes in the expressions of personality, whether or not it touches the

basic structure set by earlier experience in the family.

The vivid experience of moving from the group of little ones to the big

ones affords many children at the age of four considerable compensation

for the inevitable sense of littleness in relation to the adults at home.

This sense of bigness in the nursery group is sometimes accompanied by

an aggressive and dominating expression of the ego-enhancement to

which it gives rise, only to be followed by deflation as the child goes to

the still larger group of kindergarten in a school where he is once again

among the littlest. In our culture where the educational system is divided

into a sequence of schools elementary school, junior high school, high

school, and college or technical school the child has a sequence of in-

flating experiences in being among the oldest in each group, which are

followed by deflation as he becomes one of the youngest in the next

school.

Ego development during the preschool period is not only enhanced

by the promotion experiences during that period; it is furthered by the

conscious philosophy of many schools which regards the cardinal points

of the curriculum to be the encouragement of the child in his explora-

tions and experiments with materials and people. Children have more

space, often, than they could have at home, are greeted with more toler-

ance, and are treated to a more consistent response from calmer adult

authority. Anxiety arising from the confusion of Oedipus and authority

problems at home can be relieved by the clarity of areas of permissive-

ness and areas of tabu at school. The anxieties related to sex, which may

be heightened by an intense sibling rivalry situation at home, may also

be diluted by participation in a larger group which permits the expres-

sion and restructuring of hostilities and fears toward other children, and

the development of security with them.

In the nursery school period, differentiation in patterns of personal

interaction develops rapidly. Isaacs (1933) analyzes aspects of aggres-

sion rooted in rivalry and possessiveness, while the writer (Murphy,

1937) finds that sympathetic behavior takes a variety of forms, includ-

ing solicitude, helping, defending, comforting. From a statistical point

of view, not all varieties of personal interaction patterns are equally char-

acteristic of all children. On the contrary, in the writer's study of sym-

pathy some children used many patterns of behavior while others used

only one or two. Even among children with high frequency of responses

to other children, and a varied repertoire, one pattern such as defense of

another child, or comforting another child, or helping another child, or

warning another child would be especially characteristic of certain chil-

dren. This seems to suggest the early formation of a personality struc-

ture in which each type of social response to a specific situation (sym-

pathetic or aggressive) is channeled by a pervasive need (to be active,

670 PERSONALITY AND THE BEHAVIOR DISORDERS [21

emotional, anxious, dominating) which determines the way in which

the child will express sympathy and aggression, or other social responses.

Typical Patterns of Personality Change

We have indicated that even during the first three or four years of

the preschool period a child's "personality" may change owing to the

rapidly changing character of his physique, his abilities, and his needs,

and to the response of others to him at one time and to his changes.

The frequency of such changes or variability is implicit in a number of

statistical analyses of children's behavior reviewed in The Influence of

Social Situations on the Behavior of Children (Murphy and Murphy,

1935). Some of the important patterns of development may be dis-

cussed now.

Perhaps the simplest pattern whereby experience becomes structured

is based on this principle : the child obtains a satisfaction, wants more of

the same, gets it, and builds a pattern of wanting, getting, and expecting

a certain type of satisfaction. Early interest in food, physical romping

play, music, smearing, painting, may become established through this

simple mechanism (see principles of learning in Chapter 3).

The experience, however, may be repeated not only because the child

finds it satisfying and spontaneously demands it. It may be repeated for

the good reasons of the adults who may consciously or unconsciously

find it useful to instrumentalize the child's experience for their own

purposes. Oral satisfaction is thus encouraged to "quiet the child" when

he is given a soother. Humor, or music in the form of soothing songs

or the radio or victrola, may be used to distract him or comfort him

or keep him quiet.

If this instrumentalizing has been successful, the child may continue

the use of these soothers, oral, auditory, or whatever, for himself when

he is older and able to dose himself with comics, swing or Beethoven,

life-savers, or a pipe. The question whether this adjustive function of

the experience continues uninterrupted may depend upon the subsequent

attitudes of the culture, i.e., other children and adults whom he meets.

The pattern may be reinforced by approval : "Isn't it fine that he likes

Beethoven ?" Or it may be punished by disapproval : "Isn't it dreadful

that he still sucks his thumb at the age of six?" This cultural reinforce-

ment or conflict then determines in the end whether the simple adience

and instrumentalizing of experience has its way, or whether the child

sustains his early satisfaction with a burden of conflict and guilt, or gives

it up under pressure.

But suppose the desire is interfered with after initial satisfaction, as

through weaning, or other deprivations. Depending upon the strength

of the organic tension underlying the need, the desire may be repressed

with the help of some defense against feeling it, or may give rise to con-

tinued demands for satisfaction, or for substitutes, or for retaliation upon

the depriver.

2i ] CHILDHOOD EXPERIENCE 671

Instrumental values may also facilitate some spontaneous psychoso-

matic patterns of adjustment in the case of many children. The attention

value of a stomach-upset, the frustration-to-adult value of constipation,

are familiar enough. Similar functions also appear for temper tantrums

and perhaps for compulsive questioning or demands for gifts. But this

principle must not be carried too far, and in the case of nightmares,

phobias, hyperactivity, and vague or confused reality orientation we need

to look at more primary forces. Here the distinction of Fries and Lewi

(1938) between those who respond passively and those who respond

actively to experiences of frustration may need more elaboration. One

type of passive child may handle his problems with a rich fantasy devel-

opment, while another may withdraw more deeply into himself and fail

to use the reality world even in fantasy or dreams. One active child may

remain normal in every respect except for the development of very

restricted phobias, while another becomes scattered or "wild." There is

no evidence that such differences are instrumental in origin. On the con-

trary, it is likely that they point to the fact that each organism has its

own thresholds for breakdown, and its own pattern of breakdown when

it comes, just as it has its own thresholds for positive response to the

array of experience to which it is exposed.

Within limitations set by the amount of fixation to which such proc-

essses have led, personality is still relatively flexible in the preschool

period. Jersild and Fite (1939) showed how the child's adjustment to

nursery school may vary with the relation which he has to his group,

particularly with the presence or absence of a friend or child with whom

he feels secure : the writer pointed out how relatively impersonal aspects

of group structure could make the difference between an outgoing, active

social child and a child who scored low on social traits ; Jack (1934) and

Page (1942) demonstrated experimentally how a child's rating on shy-

ness could be changed by special training in skills in which he competed

with other children; Keister and Updegraff (1937) showed experimen-

tally how a child's attitude toward failure could be changed with under-

standing training. Most of these same points regarding the flexibility of

personality and the child's capacity to change in his attitudes toward

experience could be made also in reference to the elementary school

period (Lowenstein and Svendsen, 1938). Here we have as evidence

chiefly the demonstrations of Lewin, Lippitt, and White (1939) that

differences in aggressive behavior may result from a shift from a demo-

cratic to an autocratic pattern of adult authority.

Changes in release, in amounts of gratification or frustration, may

"make a different child out of" almost any youngster at the age of four.

I have often quoted the story of the little boy who was removed from

one nursery school for kicking, spitting, distractible behavior, temper tan-

trums. He was also biting his finger nails very badly. He was brought

to another nursery school where, when he started to spit at children, the

teacher said with amusement, "You can spit in the toilet if you want to,

but not here." Feeling his need for attention and response she handled

672 PERSONALITY AND THE BEHAVIOR DISORDERS [21

him affectionately. All of the extreme behavior for which he had been

punished in the other nursery school vanished immediately and within

three weeks he had also stopped biting his finger nails. His comment to

his mother after the first day was, "My teacher smiled at me all day

long, I like this nursery school/'

There are, however, individual differences in flexibility and rigidity of

response to experience which may account for some of the variations in

success of such efforts to help a child's adjustment. Lerner found a wide

range of such patterns in his studies of ego-blocking, and they also

appear in my studies of records of free play with miniature toys. (Lerner

and Murphy, 1941). Tentatively we may say that rigid and artificially

imposed habit-training is apt to beget rigidity in other aspects of a child's

response to experience. The report on the later development of twins

T and C (Gesell and Thompson, 1941) gives an important confirmation

of some of the expectations which we have come to have regarding the

effects of rigid training. The twin, for example, who received some hun-

dreds of hours of special, formal training writes a systematic, colorless,

constrained story-account of graduation, while the untrained twin writes

a personal, enthusiastic, spontaneous account. The trained twin draws

in straight-line and angular patterns, where the untrained twin uses

curving lines. The trained twin has fewer movement responses on the

Rorschach (indication of inner fantasy and imaginative life) than the

untrained twin. Cause and effect are of course not conclusively proven.

More longitudinal studies of individual children are needed to give us

enough data for the construction of sound principles of type-formation

in personality development in childhood.

Granting that many children still show considerable flexibility in

their response to new experience, we find some who show definite pat-

terns of change which are not necessarily related to changes in group-

structure or atmosphere. We have records of children who appeared to

be extremely passive during their third or fourth year, but who became

very active a year later, often showing marked aggression, or leadership.

We also have records of children who begin their contacts with a new

group very actively and later become shy or constrained. Their direct

outgoing methods have not been adequate, perhaps, to cope with the com-

plexity of the situations with which they have had to deal, and they must

go through a belated taking-in period to get more oriented. These

changes in extraversion and introversion are more familiar at the adoles-

cent level where we have come to expect them as a normal part of the

adjustment to the deeply significant changes in the biology of the child

and his relations with his group and with adults.

Many research studies point to approximately the third year as a peak

time for resistance or negativism (Murphy, Murphy, and Newcomb,

1937). If we see this in relation to the child's experience at that time it

seems inevitable that this should be so. Just at the time that the child

gets some sense of security in locomotion and large-muscle activities so

that he begins to feel some power over objects in his world, he also

2i ] CHILDHOOD EXPERIENCE 673

acquires some competence in speech. His increasing competence carries

along its own urge for opportunity to use his skills, to get around his

world independently, and to enjoy his new sense of self. But the adults

must teach him when, how, what, where, he can be allowed to do the

things he wants so much to do. They have a great many ideas about

things they want him to do, just when he is so full of ideas himself

which he has not had time to follow up. The result is resistance, and

often an increase in egocentric behavior. During the next year or so he

grows clearer about things; he accepts some of the definitions as to

when, where, what, and how he may use his legs and hands, and enjoys

freedom within limits. By the time he is five he has usually accepted

adult authority within limits and has a clearer ego-pattern or conception

of himself in relation to that authority. This sequence varies, of course,

with different children and the different authority patterns of adults. In

some progressive circles of the vaguer sort, children sometimes do not

get a clear pattern of authority and its limits, and may as a result have

more conflict and anxiety about authority than children who have been

handled with more simplicity. Variations on this pattern of shift from

resistance to acceptance of authority are associated with varying ego-

patterns of children such as those analyzed by Lerner and Murphy

(1941).

The patterns of change described so far have been chiefly those which

are an expression of development of one kind or another in the child's

relation to himself and people around him. More confusing to parents

and teachers are those changes which have some regressive or repetitive

origin ; for example, a child goes to nursery school for three years during

which he develops from a shy, quiet child to an active participant in all

the school activities. Then he goes to kindergarten and appears to have

"lost all that he gained" during his three years of preschool experience.

He seems to "start all over again." Actually he is repeating his earlier

experience, in the sense that he is responding to the newness of the situ-

ation just as he did three years earlier. Often the sequence of adjust-

ments the child goes through before he again becomes adjusted as an

active participant is more rapid and the period of initial shyness does

not last so long. In other cases the child "picks up where he left off" in

the preceding school, and growth seems more obviously cumulative.

Underlying these individual differences in tendency to repeat earlier

adjustment-sequences as against building on current achievement may

be patterns of personality structure especially related to the child's de-

pendence upon his relations with his external environment.

Common Experiences Producing Aggressive and Friendly Per-

sonality. In metropolitan nursery-school groups the period from three

to five enjoys increased activity, more contacts with other children, the

development of friendships, of competitive and cooperative play, and also

of conflicts and aggression, all part of the enriched social experience

which comes after the initial period of experience with objects (see

674 PERSONALITY AND THE BEHAVIOR DISORDERS [21

studies reviewed in Murphy, Murphy, and Newcomb, 1937). With great

individual differences related to the way in which different children

handle this social debut, they learn somehow to deal with the need for

defense in relation to their fellows. Most nursery schools have their own

culture, with its patterns of taking turns, respecting the rights of the

child who had it first, letting the other child have a share, etc., which are

introduced by the teachers, adopted gradually by some children and

evaded or resisted by others (Jersild and Markey, 1935; Fite, 1940).

Physical aggression has been observed to increase even through kinder-

garten in the sense that more children fight their way through a conflict

when it arises. It must always be added, however, in that kind of kinder-

garten. For this generalization cannot be applied to kindergartens other

than the types studied, and it is to be doubted whether the same thing

would be true of those with a more authoritarian regime, where aggres-

sive behavior is successfully repressed in many children. What happens

to the child who does not have this opportunity for release of hostile

feelings, and who does not develop the ability to defend himself against

his competitors or attackers, has then to be described by the clinicians.

One assumption is that those children who have learned to deal aggres-

sively with conflict situations by kindergarten age are less likely to suffer

the effects of repressed conflicts and hostility, less likely to be neurotic

than those who do not have this opportunity. There is considerable justi-

fication for this assumption in Charlotte Biihler's unpublished data on

English children, who, more socialized than Austrian children, show

many more psychosomatic difficulties of the enuresis and gastric-disturb-

ance type than do children in the groups with more social difficulties.

Along with the increase of active aggression, especially among boys,

there is an increase at about the age of five in verbal expressions of an

aggressive nature as well as competitive ones : "stinky," "skunk," "you

big fool," etc., offer outlets not available ordinarily to the three-year-old,

and are sometimes particularly consoling to the five-year-old who for

whatever reason does not have success with physical measures.

A number of developments are taking place about this same time.

Sex differences in behavior have been relatively inconspicuous among

three-year-olds. Play groups are often mixed, and games of mother and

baby, or fireman and policeman, are shared by girls and boys alike

(Hattwick, 1937; Murphy, 1937). Boys in our culture are still largely

identified with mothers, and are not ordinarily very conscious of sex

roles. The he-boy is apt to make his role and his consciousness of it felt

by the age of four or five. This is stimulated doubtless by observation

of boys just a little older who are beginning to play ball and to ape still

older boys; by adults who comment on what a big boy you are; by

clothes more differentiated from girls 1 clothes. At any rate, boys who

have been playing happily with miniature life toys reject them violently

about this age, while girls continue to accept them (Lerner and Murphy,

1941). Bravado, swashbuckling, bullying behavior may become part of

the picture as an expression of the boy's new realization of who he

2i ] CHILDHOOD EXPERIENCE 675

is, and that he is he. About the same time, costumes, jewelry, and

dress-up testify to some girls 1 increasing consciousness of femininity. All

of these aspects of the task of clarification of sex role, which takes place

in the fifth and sixth years, are tied up with the shift in the child's identi-

fication with parents, referred to earlier.

Experience Expands with Expanding Imagination. Reality ex-

periences do not have time to mellow before the child begins to expand

his range of experience through fantasy, pretense, imaginative games,

stories, and conversation. At first reality and fantasy may not be clearly

distinguished ; at the age of four, a child may be very anxious about a

wolf in Red Riding Hood, a witch in Snow White, which is delightful

a couple of years later. The period between four and six, then, is a

period of clarification of the distinction between reality and fantasy ex-

periences. The child is experimenting with his own fantasy and can take

a certain amount of fantasy from adults provided it is not too strong for

his digestion at that time. Oddly enough, the fantasy which he creates

at this time is apt to be meat that is too strong for many adults. The

child seems to be less sensitive to the idea of chopping off heads, when it

is his idea. The adult can stand a fairy story with violent elements, but

may be shocked by the violence of the child's own fantasy. The inter-

action of child and adult feelings about aggression and violence in fantasy

thus contributes to the child's ability to assimilate, or to his anxiety about

the meaning of the experiences related to the fantasy. When let alone,

his own fantasy may help him to digest painful experiences in the world

(Bender, 1941). Exposed to adult anxieties, he may have to repress

what he might otherwise have been able to deal with himself.

The development of fantasy has other implications for the develop-

ment of the child's personality also. One of these relates to the way in

which fear is assimilated by the child. Macfarlane (1939) points out that

her data appear to justify a contrast between children who adjust in-

wardly, with both fantasy and physiological reaction as indications of

inward adaptive patterns, and other children who react outwardly, with

temper tantrums, aggressive efforts, and peripheral physiological re-

sponses like eczema, in her group of outward adjustive patterns. On the

basis of our own data, I would like to offer the hypothesis that the child

who up to the age of three has been assimilating fear and other stress

experiences inwardly, perhaps with an accompaniment of considerable

nonverbal fantasy, may, after the development of language and verbal-

ized fantasy, become more overt in reactions precisely through the re-

leasing influences of communicable and objectified fantasy. Nursery

rhymes and fairy stories are, from this point of view, a traditional and

culturally accepted method of stimulating this externalization of formerly

internal reactions in the child. Differences in the child's opportunity to

relate his own internal and personal fantasy to the objective or universal

fantasies of the culture may be important in the formation of person-

ality during this period, especially in relation .to the degree of "extra-

676 PERSONALITY AND THE BEHAVIOR DISORDERS [21

version" which the child is able to achieve. Perhaps the most important

value of play groups and nursery schools is the opportunity which they

provide at this stage to externalize and thus socialize the fantasy life of

the child. When this socialization is completely and satisfyingly experi-

enced, it may constitute a deep source of security for the child which

might be likened to the sense of security that is achieved in adult life

through work, friendship and sexual and parental fulfilment.

When fears are elaborated and assimilated through fantasy with the

result that thresholds for reactivity to fear stimuli in the reality-world are

raised, we may consider that the fantasy experience has had a thera-

peutic effect. Sometimes, however, the fantasy and the emotion going

with it becomes stereotyped and cumulative, as in the case of phobias or

obsessions and the opportunity for objectified or social fantasy as such

does not help the child.

The meaning of this period of fantasy varies not only with the child's

opportunity to objectify his fantasy, but also with the unsolved problems

which feed his fantasy. Different subculture areas vary considerably at

this point. If you are a hill-country child who is taken to funerals, and

to the home of a new baby shortly after it is born, basic experiences of

birth and death are much closer to the world of reality than they are for

the usual metropolitan child who wonders where people come from and

what it is like when they die. This may account in part for the fact that

observers like Claudia Lewis (1943) find less imaginative activity among

the Tennessee children than among protected Westchester nursery school

children, who will spend hours in play sessions centered on symbolic

dramatization of "how babies get in," and "how they get out."

The basic features of the child's social experience up to six, then, have

usually included :

1. Experience with parents and other adults, some adjustment to

adult authority, and some patterns in relation to the kinds of

satisfactions expected from adults.

2. Experience with other children, awareness of sex differences and

sex roles, exposure to patterns of aggression and friendliness,

and the varying social techniques of different children.

3. Experience of himself, his body, its competences, the reactions it

gets from other people, the satisfactions it gives, the difficulties

it presents.

4. Experience of fantasy, both emerging spontaneously in the child's

mind, and fed by the stories of adults and other children.

All these aspects of experience, assimilated by an organism with its

own thresholds for adjustment and tension in different areas, produces

the personality structure that we confront when we come to know any

six-year-old. By this time each child usually has his characteristic themes

for fantasy: bigness, mountains, or towers; dominating or punishing

adult, policeman, or parent ; ideal adult, princess, Lone Ranger ; threats

2i ] CHILDHOOD EXPERIENCE 677

from nature, creatures of prey, death, fire, whirlpool ; cultural demands,

baths, shampoos, bedtime, keeping clean ; primitive experiences, eating,

defecating, messing, sucking, drinking, or masturbating. When he draws

or paints he is likely to produce patterns clearly characteristic of these

fantasy themes and the free or constrained space-world in which he lives :

he starts with a boundary line or he approaches his paper more freely ;

he tightly fills up space or he leaves it open; he draws in squares or

curves with rigid forms or free and lively ones; his figures may be a

child alone or in a group; he paints with sensuous abandon or with

great control. Thus he reveals the dramatic content of life and his way

of handling it.

Elementary School Experience. Even at six, we often find that

children have clearly defined personalities: an artist, an architect, a

mechanic, a little mother, a scientific observer, a verbalist, or a social

butterfly. What, then, can the next six or seven years do, and what

does their experience mean to the child? This depends upon the per-

sonality. Some personalities, which have already decided to vote on the

side of the Tories, convention, the priests, and "the right" are likely to

continue in the path laid down by the social structure, provided no major

obstacles to this path present themselves. Others, at another, not the

other extreme, are so traumatized that their relation with their fellows

will always be a deviant one. Some six-year-old rebels may remain

rebels for the rest of their lives; others become rebels later for other

reasons.

Within a wider group, basic personality structure, ways of perceiving

and experiencing, remain consistent. A child with oral and narcistic

structure, at three does not usually change to a compulsive or a narrowly

constricted type at eight. But this underlying personality structure may

find expression in many different ways, and a delinquent career may be

made or prevented by the experience which the child has between six

and fourteen, granted the underlying personality remains consistent.

That is, a given set of needs and attitudes may find ways of satisfying

and expressing themselves that are acceptable to the culture, or ways

that are considered taboo. Recent studies of prevention of delinquency

have given clear evidence of this (R. J. Levy, 1941).

Whether neurosis can be prevented with equal effectiveness is an open

question; I know of no comparable studies which attempt to deal with

paired groups, giving treatment to one group and not to the other. The

outcome might be harder to judge, since neurosis is often handled by

the individual skilfully enough to prevent detection by mere observation

of behavior.

The large group of normal children, whose personality structure main-

tains a certain recognizable consistency beneath striking differences in

behavior, share a variety of significant experiences during the elementary

school period (Biber, et a/., 1942). First, perhaps, is the new experience

of participation in a more structured group, a larger group, with a more

678 PERSONALITY AND THE BEHAVIOR DISORDERS [21

teacher-directed experience. This is true not only of the majority of tra-

ditional schools where children sit at desks in a row, hands folded, to

recite when told to. It is also true to a lesser extent of progressive schools

where school-desks are moved about, materials are adapted to the indi-

vidual child and decisions are often made by vote. In either case, the

child has a more complicated group situation, and has to meet the ex-

pectation that he will conform to certain behavior patterns as a member

of this larger group. Children experience this change in different ways,

depending on their previous experience and ways of handling authority.

Children who have accepted clear authority from parents usually are

ready for school, while children who have had a great deal of freedom

either through permissiveness or through neglect are apt to find the new

situation more demanding. In the progressive atmosphere in which

Biber and her associates studied seven-year-olds, open complaints that

"grownups are too bossy" were frequent. This is a different response,

with different meanings for the children who show it, from the surrep-

titious spitball-throwing defiance shown by rebellious minorities in auto-

cratic schools. Children with a great deal of inner life and capacity to

keep their thoughts to themselves may conform outwardly, with inner

reservations. Children with very open, outgoing patterns of responding

may grumble and complain a great deal at this new state of affairs. The

former will of course appear more adjusted, and sometimes they are.

Going to school often means more independence, going around town,

shopping for the family, going to the movies, playing with a group of

children in the neighborhood, and joining clubs or other extra-home

groups. All of this means exposure to a wider cultural field, and this

may present new reinforcement of old experiences, or new conflicts.

These have been described by Hartshorne, et al. (1930), who pointed

out that for some children the conflict between home and school grows

more acute and cumulative through the elementary school.

Larger groups mean new structures and organization, in the form of

rules, first of a simple sort like those in hide and seek where each child

takes the role of "it," pursuer at times and pursued at other times. Later,

as J. E. Anderson (1939) has pointed out, roles become more differ-

entiated, as in baseball and football, and the structure of the game is

tightened up. We find little analysis of the relation of personality struc-

ture to capacity for adaptation to these new types of organization, to

supplement Piaget's (1932) delineation of stages in the child's relation

to rules.

Observation of seven-year-olds indicates that it is easier for some

children than others to enjoy this type of experience ; some children prefer

through the elementary school years the more loosely structured activities

which allow room for fantasy, such as cops and robbers or dramatic play.

In other words, the new experiences of this age level also mean very dif-

ferent things to different kinds of children. Similarly the more defined

"manners" expected of children in this period may mean an opportunity

2i] CHILDHOOD EXPERIENCE 679

for adult approval to some children, or an interference with "my own

ideas" to other children.

Along with increasingly differentiated structure in group activity,

there is considerable pressure toward greater objectivity: the curriculum

is usually directed toward the achievement of basic skills and the expan-

sion of information about the world of nature, city life, communication

systems, local and national geography (Biber, et al., 1942). Both this

trend and the opportunity to explore the environment with greater

freedom and independence doubtless contribute to whatever lessening of

interest in organic functions and biological experiences we find in the

so-called "latency period." Actually, the spontaneous needs of the child,

stimulus from movies, from observation of people around him and of

animals, keeps sex interest more vigorous than adults often admit. Other

interests in masculine and feminine role, in babies, their care and devel-

opment, might well get more attention in the curriculum than they

usually do.

The increasing rigidity of sex differentiation is itself a stimulus

(Moreno, 1934). Most nursery schools allow children to use common

open toilets, in order to encourage children to get accustomed to sex dif-

ferences in anatomy. At school, toilets are separated, closed, and privacy

emphasized. Clothes are different, and games are increasingly distinct,

as boys grow into the rougher games like football, and form gangs which

exclude girls. Sometimes considerable competition accompanies this dif-

ferentiation and is expressed in verbal hostility, teasing, etc. This seems

less conspicuous in a progressive school where there is less pressure from

adults to differentiate sex roles than it does in more traditional groups.

Along with the new emphasis on objective interests encouraged by

the school curriculum, there is an equally important emphasis upon

objective achievement, with its sources of new stimulus and new anxiety.

Plant (1937) urges that school and home recognize their respective areas

of security the school's job being to develop the "whatness" side of the

child's personality, while the job of the family is to give the child security

in "who" he is. Biber and her co-authors (1942) give extended con-

sideration to the meaning of their findings that seven-year-old children

appear to be especially conscious of work-standards, and typically run

down or depreciate their own work ; it is suggested that this is part of

the process of assimilating and adjusting to the new standards of work

which school brings them.

It was to meet the problems indicated by the frequency with which

this institutionalized emphasis upon adequacy of accomplishment, and

the competition that went along with it, produce anxiety and person-

ality problems in children, that the progressive education movement has

urged the elimination of marks, stars, and other trappings of status and

achievement, substituting less honorific methods of encouraging the

child and correcting mistakes. However, progressive methods in reading

have not eliminated "reading problems," and the effect of failure with its

68o PERSONALITY AND THE BEHAVIOR DISORDERS [21

consequent insecurity for the child is dramatically discussed by Dr. Pres-

ton (1940) and other observers of elementary school children.

The point that failure in reading may not be due solely to the failure

of either modern or older methods is implicit in Dr. Liss' discussion

(1940) of mechanisms involved in learning. If we follow his approach to

its logical conclusion, we may say that the whole school and learning

experience itself means something different to each child, depending

upon the pattern of his identification with the achievement values and

successes of parents ; and with the emotional connections which are made

between the school situation as a whole teachers, children, materials,

and tasks and the pattern of values and resistances or anxieties which

the child brings to school.

The increased structuring of activity and direction by adults doubtless

creates certain new tensions, which may be related to the new patterns

of withdrawal : having secrets, secret clubs, and secret activities. Comics

include stories concerned with child-adult authority problems, of which

the Katzenjammers is still perennial and not the only one of its kind.

Authority conflicts are also sublimated in drawing, writing skits, or just

in extra-curricular crabbing, depending again on the resources of the in-

dividual child.

Against this general background of experiences provided by elemen-

tary school culture, we find individual children who fit with greater, and

with less, success into the demands which the culture is imposing on

children at this age. The problem of sex differentiation is confused and

difficult for the artistic boy who is not physically vigorous (less or no

problem if he is physically vigorous) and the aggressive girl or the large

fat girl. Depending on the rigidity or flexibility of the specific subculture

group, the presence or absence of bullies, sympathetic teachers, under-

standing parents, these deviations from the demands of the culture may

lead to serious traumas or to a sturdy individuality.

Experiences of Children in Minority Groups. Up to this point

we have discussed the experiences of children against a general back-

ground of research and observation of average children in middle class

homes in metropolitan areas. This is necessary because of the lack of

adequate material on other culture groups, especially rural children, or

children in the highest economic brackets, who go through private schools

where psychologists do not do research.

Just a few notes on the experience of children in special groups may

be added, however. The increase of intelligence of Negro children in

proportion to the length of their exposure to the relatively stimulating

experience of town schools, reported by Klineberg (1935), and the corre-

sponding improvement of children in the Iowa studies, are probably par-

alleled by other changes. Personality development would probably

respond even more dramatically to a shift from an environment that was

emotionally malnourishing to one which had adequate emotional vitamins.

2i ] CHILDHOOD EXPERIENCE 681

E. and R. Horowitz (1939) have described the process with which

parents inculcate race consciousness in children, but no studies have been

made of the processes by which some children in minority groups develop

socialized personalities as compared with those who become aggressive in

an antisocial way, or merely socially unpleasant.

Subculture conflicts experienced by children of different racial, na-

tional, and religious backgrounds, and children's ways of dealing with

these conflicts deserve more attention than they have received. Subtler

onflicts between families in a neighborhood where some parents are

strict and some are permissive may be illustrated by the plight of the

seven-year-old girl who ran to her mother weeping and asked, "You are

too 'strict enough/ aren't you, mommy?" Ego-threats of 30% of our

children who belong to minority groups (Negro, Jew, Oriental, etc.)

originate in experiences of exclusion or jeering, and are either offset by

intra-family love and security or aggravated by conflict within the family,

lack of attention from working parents, anxiety about economic security,

or awareness of race conflicts increased by war.

"Problem Children"

Deviations in the personality development of children, or "problem"

children, are being looked at from a variety of points of view, since child

psychiatry and even the field of child development are so new that a

stable orientation has not emerged. An extreme emphasis upon symp-

toms appears to be characteristic of some approaches such as that

in Kanner's Child Psychiatry and of many of the studies of nervous

habits, and of the frequency of "problems"; however, in action the

child guidance movement is eclectic and usually dynamic rather than

atomistic in approach, and attempts to deal with the total picture

of difficulties, both organic and psychogenic in origin, presented

by a child. D. Levy's (1939) work on maternal overprotection deals

with something deeper than a collection of symptoms: it is concerned

with the total pattern of kinds of behavior rooted in a basic attitude of

the mother, and with the total pattern of behavior of the child rooted in

the child's response to the overprotective attitude of the mother. This

tendency to approach symptoms (aggressiveness, dependence, rebellious-

ness, etc.) as part of a structure of parent-child interaction is character-

istic of considerable recent work, both research and clinical (Fromm-

Reichmann, 1940; Symonds, 1939).

At the same time there is increasing interest in better understanding

of types of behavior for themselves ; behavior in children which is like

schizophrenic behavior in adults has attracted especial attention (Despert,

1938, 1942; Bradley, 1941 ; Isaacs, 1939). In our own records of nearly

100 normal children, miniature samples of several different kinds of be-

havior that resemble adult breakdown behavior are to be found : "cata-

tonic" behavior, "schizophrenic" language, "compulsive characters," and

the like. In some of these cases, the behavior has appeared during the

682 PERSONALITY AND THE BEHAVIOR DISORDERS [21

preschool phase of adjustment to the first outside group and being emo-

tionally weaned from the parents, and has disappeared by the time the

child reached first or second grade. In other cases this change did not

occur. There is some evidence from the family histories that these

patterns of response to periods of unsatisfactory adjustment may have

organic bases, but only a small per cent of schizophrenic children have

psychotic parents.

The patterns of adjustment of some children are weighted by physi-

ological factors rather than by environmental ones ; with others the oppo-

site is true according to Macfarlane (1939). Examples of physiological

weighting would be persistent low energy level and mucous membrane

irritability (e.g., gastro-intestinal irritability). In the early periods these

are heavily weighted factors in internalized and withdrawn trends of

response. Conversely, high energy levels and peripheral irritability (e.g.,

skin allergies) are important factors in externalized patterning. An ade-

quate discussion of psychosomatic aspects of personality development in

children would require a chapter in itself. The reader will find leads in

the bibliographical listings in a paper by Bruch and Touraine (1940), in

the paper of Chobat, et al. (1939) on allergic children, in Hall's (1940)

work on asthma, in Harrower-Erickson's (1940) study of the effects of

brain lesions in children, and in the study of behavioral effects of testo-

sterone injections in young boys by Bize and Moricard (1937). Stone

and Barker's (1939) study revealing differences in interests between

post- and premenarcheal girls of the same age points to another evi-

dence of the influence of biochemical factors upon responses to the

environment.

Situational weighting is illustrated by Macfarlane (1939) in the fol-

lowing examples: response patterns associated with intimate personal

contacts of the early periods of physical dependence, affectional, hostile,

tearful, etc., are critical ones for psychosexual adjustments at maturity.

Unconscious ambivalent drives in parent-child relationships and strained

marital adjustments are associated with anxiety trends and compulsive

or explosive behavior in children; Baruch (1937) finds similar results

in her study of the relation between marital relationships and children's

problems. Being an older child in a pair is conducive to a different pat-

terning from being a younger child. For examples, the older of a pair of

boys two or three years apart is more apt to be insecure in social rela-

tionships, the younger insecure about his intellectual ability.

For some time the statistical studies of children's problems, such as

those of Tilson, Hattwick, or Olson (summarized by Murphy, Murphy,

and Newcomb, 1937), have indicated that problems do not come singly

but in bunches, as any clinician would expect who approaches behavior

not segmentally or phenotypically, to use Lewin's term, but in terms of

genotypic forces. Macfarlane's approach takes hold of both horns of

what for a time was a scientific dilemma, showing how the particular

symptoms in which an adjustment (or anxiety) problem is expressed

will be an expression of organic thresholds as well as conditioned pat-

2i ] CHILDHOOD EXPERIENCE 683

terns of the individual child's personality (see also Ribble's approach in

Chapter 20).

Partly because of the fact that many of the multitudinous "problems"

of the preschool period evaporate or are translated into subtler and more

socialized behavior during the elementary school period, our picture is

very incomplete when we look at it longitudinally. Except for the discus-

sions of schizophrenic behavior in childhood referred to above, there is as

yet no adequate longitudinal study of the processes of character-formation,

either starting from the hypotheses intrinsic in the oral, anal, genital type

theory of Freud and Abraham, or any other framework oriented to the

question of the integrated personality as a whole. The case-studies pre-

sented in Stuart's (1939) growth-studies are the nearest approach, but

we shall have to wait for results of research now under way and to be

planned before we have an empirical demonstration based on actual re-

search data of the process of formation of basic personality structure in

different subgroups in our culture. Such a demonstration will have to

look at growing personalities in terms of the individual pattern of sus-

ceptibilities for response to the particular parental, sibling, school, and

neighborhood experiences to which they are exposed, and will have to

take into account the continuing dynamic interaction of the partly

crystallized aspects of the personality, and the more flexible ones, with

the new stimuli, pressures and satisfactions which each developmental

stage provides from within and from without the child.

Summary

Childhood experiences which contribute to the formation of person-

ality may be conveniently looked at from the side of growth and that of

expanding social relationships. Growth experiences after the weaning

period include the experience of increasing manipulative skill, making

possible self-feeding, self-dressing, organization of objects such as that of

building and dramatic use of objects ; locomotor or large-muscle skills,

making possible the experiences of climbing, jumping, swinging, bicycle

riding, as well as running to and away from places and objects feared or

of interest ; language, with its possibilities of expression of wants, obser-

vations, feelings ; fantasy, with its new world of reconstruction and dra-

matic reliving of experiences actual, feared, desired ; increasing clarity of

form-perception, as an aspect of clearer grasp of objective realities, and

making possible both analytic and creative manipulation of reality; in-

creasing grasp of concepts of space, time, object-relationships, and hu-

man relationships, making possible adjustments through substitution,

postponement, construction, submission to standards ; grasp of complex

sequences, making possible participation in complex games and social

structures, and maintaining roles of different sorts at different times.

Changing social experiences include changing areas and patterns of

expression of parental authority, companionship, and love, in response or

reaction to the changing status of the child resulting from the growth

684 PERSONALITY AND THE BEHAVIOR DISORDERS [21

patterns just summarized; stimulation, rivalry and love in relationships

between siblings ; sequential changes in relation to members of the neigh-

borhood or preschool play group, in which a common but not universal

pattern is the sequence from isolated to parallel to cooperative to group

play; exposure to a wider environment, which in metropolitan culture

includes doctors, police, firemen, grocers, and other commercial persons,

and in some rural sections may include participation in funerals, celebra-

tions of births ; later membership in a gang, and in the more regimented

structures of school life. In metropolitan culture, exposure to radio and

movies provides certain types of experiences not included in the other

categories.

Variations in the content and meaning of these experiences rooted in

variations in the child's own pattern of growth, and the variations in the

pattern of expanding social relationships in different subcultures and dif-

ferent families go far toward determining the basic structure of the child's

personality and provide the background against which his reaction to his

individual experience of puberty must be understood.

BIBLIOGRAPHY

STANDARD SECONDARY REFERENCES IN CHILD PSYCHOLOGY

BURKS, B. S., & JONES, M. C. 1936. Personality development in childhood.

Monogr. Soc. Res. Child Develpm., No. 4.

JERSILD, A. T. 1940. Child psychology. New York : Prentice-Hall.

MURCHISON, C. (Ed.) 1931. A handbook of child psychology. Worcester,

Mass.: Clark University Press.

MURPHY, G., MURPHY, L. B., & NEWCOMB, T. 1937. Experimental social psy-

chology. (2nd ed.) New York: Harper.

MURPHY, L. B. 1941. Social and emotional development. Rev. educ. Res., 11,

. 479-501.

SKINNER, C. E., & HARRIMAN, P. L. (Eds.) 1941. Child psychology: child de-

velopment and modern education. New York : Macmillan.

SPECIFIC REFERENCES FOR CHAPTER

ACKERMAN, N. W. 1938. Constructive and destructive tendencies in children: an

experimental study. Amer. J. Orthopsychiat., 8, 265-285.

ALDRICH, C. A. 1939. The role of gratification in early development. Proc. 3rd

Bienn. Mtg. Soc. Res. Child Develpm. 1-2. Abstract.

ALPERT, A. 1941 a. Education as therapy. Psychoanal. Quart., 10, 469-474.

1941b. The latency period. Amer. J. Orthopsychiat., 11, 126-133.

AMEN, E. W. 1941. Individual differences in apperceptive reaction : a study of

the response of preschool children to pictures. Genet. Psychol. Monogr., 23,

319-381

ANDERSON, H. H. 1937. Children in the family. New York: Appleton-Century.

1939a. Domination and social integration in the behavior of kindergarten

children and teachers. Genet. Psychol. Monogr., 21, 287-385.

1939b. The measurement of domination and of socially integrative behavior

in teachers' contacts with children. Child Develpm., 10, 73-89.

ANDERSON, J. E. 1939. The development of social behavior. Amer. J. Sociol.,

44, 839-857.

ANDERSON, J. P. 1940. The relationship between parental affection and dominance

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Chapter 22

ADOLESCENT EXPERIENCE IN RELATION TO

PERSONALITY AND BEHAVIOR

By PHYLLIS BLANCHARD, Ph.D.

IT is NOT EASY to evaluate adolescent experience as a determinant in

the development of personality and behavior, for the relevant material

comes from studies of adolescence oriented from such different view-

points as the psychological, psychoanalytic and sociological and varied

in methodology from controlled experimental research, questionnaire

returns and statistical reports to clinical and general observations. More-

over, there is a continuity in the personality development from birth to

adult life, with intimate relationships between the experiences of in-

fancy, childhood and adolescence, so that it is often difficult to state with

certainty that phenomena observed during or after adolescence are to

be ascribed to adolescent experience alone.

In order to reduce these difficulties, we shall exclude two groups of

adolescent individuals, in whom definite physical pathology or mental

deficiency complicates the picture, and confine our discussion to adol-

escence when uncomplicated by either of these conditions. In clinical

diagnosis and treatment, it is important to take into account any phys-

ical or intellectual handicaps that exist in a particular case. But in this

chapter, our concern is less with individual problems and more with

general theoretical formulations. Hence we are justified in excluding,

so far as possible, gross physical or mental pathology, for the purpose of

facilitating the task of relating adolescent experience to personality and

behavior.

General Psychological Literature

The pioneer work on adolescence in this country was G. Stanley

Hall's two volume treatise (1904), which encompassed the biological

aspects of adolescence, its normal and abnormal emotional phenomena,

its psychology and psychopathology. It was Hall who first described the

emotional instability of adolescence but at the same time noted the

enrichment of the emotional life at puberty ; his description of adolescent

anger (pp. 367-370, Vol. 2) is full of keen observations concerning

efforts to conceal and suppress it, revengeful phantasies, etc. ; his discus-

sion of youthful suicide or suicidal phantasies includes such motivations

as grief over loss of love, wishes to be revenged upon parents or a loved

one who does not respond, disappointment in self- and self-disillusion-

692 PERSONALITY AND THE BEHAVIOR DISORDERS [22

ment (pp. 374-384, Vol. 1). It was Hall, too, who first collected from

many sources and brought together data on the physical growth and

physiological changes at puberty and indicated the relationship between

biological changes in the adolescent organism and the psychological

phenomena observed at that period of life.

Later writings by psychologists have stressed the necessity for con-

sidering the physiology of adolescence in order to understand its psy-

chology. Luella Cole (1936) has given an excellent summary of the

usual adolescent bodily changes, such as the acceleration of physical

growth, the unequal rates of growth in different parts and organs of the

body, complex glandular changes, maturation of the reproductive organs

and functions, development of the secondary sexual characteristics, etc.

She considers that during adolescence the organism is in a state of dis-

equilibrium, due to the unevenly developing organs and functions, and

therefore can be thrown into a state of emotional disturbance very

readily. Hence, the adolescent tends to respond emotionally to com-

paratively slight stimuli. Most other authors also mention considerable

emotional instability as characteristic of adolescence.

There is general agreement among authors that another cause of

seemingly exaggerated emotional responses during adolescence is the

strain produced by the necessity of making readjustments to the self

and to others. This necessity is imposed by the adolescent's own drives

and desires as well as by the expectations of the social group in which he

lives. Jones (1938) states that the adolescent must become able to

direct his own behavior with increasing independence of parental guid-

ance or control, must develop satisfactory relationships with the opposite

sex, and must achieve integration of his own personality. Hollingworth

(1928) mentioned four major adjustments during adolescence: "psycho-

logical weaning" from the family, vocational choice and preparation,

establishment of heterosexuality, and organization of the self. A long

list of authors could be quoted in agreement on the viewpoint that suc-

cessful adjustments in these fields during adolescence are of fundamental

importance for personality and behavior in adult life.

There is further agreement that childhood experiences and parental

attitudes may favor these adolescent adjustments or interfere with them,

causing them to be delayed or in extreme instances not accomplished

adequately at all. Parental efforts to prolong childish dependence or to

continue strict control, parental restrictions of the adolescent in social

relationships with the opposite sex, parental demands for vocational

choices out of harmony with the adolescent's own interests or abilities,

all are frequently mentioned as leading to difficulties in adolescent efforts

at readjustment. They are also productive of increased conflicts between

the adolescent and parental or other adult authority an aspect of adol-

escence which has been stressed by many writers on the subject. These

family conflicts do not break out suddenly at adolescence as frequently

as might be assumed, however. In clinical experience with adolescents

and their parents, an increase of conflict previously present in the parent-

22] ADOLESCENT EXPERIENCE 693

child relationships is seen more often than friction that begins de novo

at adolescence.

Experimental and Statistical Research

While the physiological changes during adolescence have been re-

garded as contributing to emotional instability, it has also been assumed

that the physiological maturation at puberty is accompanied by tendencies

toward psychological maturity and by the reinforcement of sexual and

other drives, so that inner forces impel the adolescent toward hetero-

sexuality and toward new interests and adjustments. Experimental

research on adolescence is not extensive but the data from such investiga-

tions as have been made seem to confirm this hypothesis.

Stone and Barker (1937) gave the Pressey Interest- Attitude Test

and the Sullivan Test for Developmental Age to 175 post-menarcheal

girls (girls who had menstruated) and to 175 premenarcheal girls (who

had not yet begun to menstruate). The post- and premenarcheal girls

were paired for age and there were no important differences in the social-

economic status of their families. Analysis of responses to the items of

the Pressey Interest-Attitude Test showed that the post-menarcheal

girls gave the mature responses with statistically significant greater fre-

quency than the premenarcheal girls of the same age. On the Sullivan

Test, the post-menarcheal girls likewise gave mature responses more fre-

quently than premenarcheal girls of the same age. The post-menarcheal

girls were more interested in their physical appearance, reported more

heterosexual interests and activities, had more tendency to avoid vig-

orous physical exertion, indulged in more daydreaming, and were more

concerned over conflicts in the family life.

In this study, Stone and Barker noted those groups of items on the

Pressey and Sullivan tests which seemed to differentiate better than

other items between post-menarcheal and premenarcheal girls. Using

these differentiating items and adding new ones, they developed an

interest-attitude test which they then gave to a larger number of girls.

In this second study (1939), in order to exclude the influence of the

factors of chronological age and social-economic status, two groups of

564 post-menarcheal and 387 premenarcheal girls were subdivided into

smaller groups, matched for age (within five to fifteen days) and also

matched for similarity of social-economic status of the families. Racial

influences were excluded by limiting the study to American-born girls

of middle and north European stock ; none of Hebrew, Negro, Mexican,

Oriental or south European stock was included. As in the preceding

study, this investigation with a larger number of subjects showed that

post-menarcheal girls gave mature responses on the interest-attitude test

in larger proportion than premenarcheal girls of approximately the same

age, social-economic background and racial stock ; heterosexual interests

and activities were indicated for more post-menarcheal than premen-

archeal girls, regardless of chronological age; concern with personal

694 PERSONALITY AND THE BEHAVIOR DISORDERS [22

adornment, disinclination for vigorous physical exercise and daydream-

ing were much more characteristic for the post-menarcheal than for the

premenarcheal girls.

Sollenberger's study (1940) of sexually mature adolescent boys com-

pared with boys less mature sexually was made with only a small num-

ber of subjects, but nevertheless should be mentioned. Sexual maturity or

immaturity was determined by analysis of the urine: if the urine con-

tained a high content of male sex hormone, the boy was regarded as more

sexually mature ; if the male sex hormone content was low, the boy was

considered less mature sexually. A preliminary trial of three different

tests led to the selection of the Furfey Test of Developmental Age, which

was then given to ten boys whose urine had a high male sex hormone

content and to thirteen boys with low male sex hormone content in their

urine. Analysis of the test responses revealed that the more sexually

mature boys (those whose urine had high hormone content) had greater

interest in personal adornment, heterosexual activities and strenuous

competitive sports than the less sexually mature boys (those whose

urine had low hormone content).

Garrison (1940) and Partridge (1939) have summarized several

studies of the interests and activities of children and adolescents, but in

these investigations the comparison was made on a chronological age

basis, not on such evidence of adolescent maturation as the establishment

of menstruation in the girls or increased secretion of male sex hormone

in the boys. However, it can be inferred that a large proportion of junior

and senior high school students would be adolescents and that lower

grade pupils seldom would be adolescents. Hence it is worth noting that

studies of the interests and activities of these age groups for the most

part indicate a trend toward more mature and more heterosexual in-

clinations among high school students. This is in harmony with the find-

ings of the more carefully controlled experimental investigations previ-

ously mentioned.

Willoughby (1937) summarized data on sexuality during the second

decade of life, quoting from studies made by a large number of in-

vestigators. Many of the studies employed questionnaire or interview

methods, used with adult subjects, so that much of the material de-

pended upon conscious memories of adults with reference to their sexual

experiences during childhood and adolescence. A large proportion of

individuals remembered striking impressions about sex received before

puberty ; the sources of these impressions were varied, but information

about sex was obtained from reading, from companions outside the home,

or from other sources outside the family, a little more often than from

parents. Adolescent attitudes toward the phenomena of sexual matura-

tion differed greatly: some adolescents reacted with pleasure or sexual

excitation but many felt shame, disgust, or other negative attitudes.

Frankly erotic dreams were common for boys, rare for girls : an adoles-

cent period of masturbation was more characteristic for boys than for

girls. Data on homosexual tendencies suggested more individuals were

22] ADOLESCENT EXPERIENCE 695

homosexually inclined than is usually considered probable, but for the

most part their homosexuality seemed due to restrictions of the environ-

ment upon opportunities for heterosexual companionship and in only

small measure a deeply ingrained aspect of personality development.

From all the data, which were reviewed in much more detail than the

selected high lights given above might imply, Willoughby drew certain

general conclusions to the following effect. Interest and curiosity about

sex begins in early childhood ; during the second decade of life the

glandular changes at puberty greatly reinforce sexual drives and desires,

and these probably are increasingly intensified up to a point somewhat

beyond the end of the second decade. Inhibiting influences on sexual

drives may be exerted by negative attitudes, or moral and ethical ideals

and conflicts between sexual drives and these inhibiting forces may be

severe enough to produce neurotic symptoms or to turn the individual

away from heterosexuality to substitute forms of sexual gratification,

such as prolonged masturbation or homosexuality.

Stott's recent researches (1940a, b) are of interest to our discussion

in so far as they seek to test the theory that personality integration during

adolescence may be fostered or hindered by parental relationships. Stott

found that serious criticisms of parental behavior by adolescents tended

to coincide somewhat with low personality scores obtained by averaging

the ratings on several personality tests. Parental behavior, particularly

of the mother, appeared to be most significantly related to the personality

development of adolescent boys living in city homes ; parental conduct

seemed less important for the personality development of boys living on

farms or in small towns and for the personality development of girls in

all three types of environments. Punishment (scolding, slapping, whip-

ping, being made to stay at home) correlated slightly with low scores

on the personality tests, particularly in items relating to self-reliance.

Boys and girls living on farms apparently were not punished as fre-

quently as those living in cities or towns and were less affected by punish-

ment when they did receive it.

Partridge (1939), in a chapter on young people in the family, has

summarized statistical studies on the relationships between parents and

adolescent boys and girls, which lead to the following conclusions : Inti-

mate and confidential relationships with parents, particularly with the

mother, are definitely connected with good adjustment during adoles-

cence; maladjustment is much greater among the boys and girls who do

not have harmonious, confidential relationships with parents. Poor

marital relations between the parents and very severe parental discipline

of children contribute heavily to adolescent and adult maladjustments.

Cultural Studies

In some primitive cultures, for instance among the Trobriand

Islanders as described by Malinowski (1929), adolescence is a period

in which considerable freedom for prenuptial sexual relationships is per-

696 PERSONALITY AND THE BEHAVIOR DISORDERS [22

mitted, in contrast to our own culture, in which premarital sexual rela-

tionships are out of keeping with the mores and a period of sexual

abstinence conventionally is expected during adolescence in spite of the

individual's biological sexual maturity. Cultural viewpoints emphasize

this disharmony between biology and culture, in our society, as a con-

tributory factor in the emotional instability of adolescence and in the

emotional conflicts at that age. Mead (1930) supports this conclusion

by citing examples of primitive cultures characterized by considerable

adolescent freedom in contrast to others where adolescent sexual be-

havior is subject to very strict taboos. She states that little adolescent

instability and conflict is to be found when the culture imposes few re-

straints but that adolescent instability and maladjustments are evident

in cultures imposing severe restrictions on behavior or fostering in-

hibiting attitudes toward sex.

The cultural approach suggests that not only adolescent instability but

also friction and conflict with parents during adolescence result largely

from cultural influences. According to the authors of Frustration and

Aggression (1939), the adolescent is an adult physiologically but socially

is still regarded very much as a child and surrounded by many of the

restrictions of childhood. Both sexual activities and personal independ-

ence are denied to the adolescent in our American culture, so that he is

frustrated in securing satisfaction for both sexual drives and desires for

personal independence and responsibility. The adolescent naturally reacts

aggressively to this situation of frustration, so that rebellion against adult

authority and conflicts with parents are seen as expressions of aggres-

sion toward the frustrating agents. These authors further suggest that

the adolescent, through a trial and error process, has to attempt to find

substitute satisfactions for the sexual and self-assertive strivings that

cannot be directly gratified. As he succeeds in finding substitute satis-

factions, he feels less frustrated and therefore his aggression diminishes.

Thus the rebelliousness of early adolescence tends to be followed by a

period of decreasing rebellion and lessening of family conflicts.

It should be noted that cultural influences do not operate upon the

adolescent merely as restrictions imposed by external social authority.

The individual has been exposed to the culture in which he lives from

the time of birth and by adolescence has absorbed much of this culture

into himself in the form of ethical ideals and standards of behavior. This

way in which the culture affects the adolescent may be even more impor-

tant than the demands of the culture as imposed upon the adolescent by

parents and other adults acting as its agents, as we shall see in the

following section on psychoanalytic theories.

Freudian Theories of Adolescent Development

In order to outline some of the Freudian viewpoints on adolescence,

it is necessary to start from the background of these psychoanalytic

theories of childhood psychosexual development and the. structure of the

22] ADOLESCENT EXPERIENCE 697

personality. The Freudian literature describes three principal stages of

preadult sexual development : the period of infantile sexuality, the latency

period and adolescence (see Chapter 20 by Kibble). The erotic phe-

nomena of early infancy are called pregenital, because they are con-

nected with other parts and functions of the body than genital ones. By

the age of four or five, however, the genitals become the chief erogenous

organs and there is pleasure in masturbatory manipulations of the gen-

itals. Coincidentally, the phenomenon known as the Oedipus complex

may be observed in childish fantasies about sexual relationships and

birth which often center around having babies with the parent of the

opposite sex to the child.

By the age of six or seven, both the Oedipus complex and the period

of infantile sexual development normally have come to an end. The

child has begun to substitute other interests and activities for sexual

curiosity and sexually colored fantasies ; in other words, he has repressed

and sublimated his sexual interests and entered the so-called latency

period, which normally will not terminate until shortly before puberty.

As the young child turns away from the Oedipus complex, the normal

tendency is also to identify more strongly than before with the parent of

the same sex and thus to begin more differentiation along masculine or

feminine lines.

The psychoanalytic concept of personality structure includes three

chief aspects called the id, the ego, and the super-ego. The id is used

as a collective term to include all the instinctive and emotional drives of

the human organism, such as the sexual and aggressive drives. By super-

ego is meant that part of the personality which is built up through identi-

fications with parents and others and in response to cultural pressures.

It is suggested that at first the child accepts adult standards and con-

forms to them in his behavior because conformity brings love and ap-

proval while nonconformity is disapproved or punished. The young child

therefore yields to the requirements of the adults who care for him in

order to have the affectionate relationships with them which he wants

and needs. Very soon, however, because of his love and admiration for

parents or other adults and also because it is pleasanter to direct and

control his own behavior than to have constant instruction and control

from others, the child takes many of the standards and requirements of

his intimate adult world into himself and makes them his personal ideals

and standards of conduct. His conformity then becomes necessary in

order to preserve his own self-respect and to avoid self-criticism and

feelings of guilt. Thus, by the time the child enters the latency period,

his own super-ego is partly formed and operates to control many of his

id-drives. Super-ego development continues through the latency period

and adolescence, probably even through the young adult years of life,

being modified somewhat from family patterns through the ever broad-

ening social relationships outside the family circle.

The ego is best described in terms of its functions. One of its func-

tions is to act as mediator between incompatible demands arising from

698 PERSONALITY AND THE BEHAVIOR DISORDERS [22

the id and the super-ego and to find ways of action that provide some

satisfaction of the id-drives without behaving too much in opposition to

the ideals and standards of the super-ego. Another ego function is the

evaluation of reality situations and the adaptation of behavior to them.

Nunberg (1931) has given an excellent presentation of the Freudian

theories of personality development during infancy, childhood, and adoles-

cence. At puberty, he states, there usually is a brief revival of early in-

fantile sexual interests and a reactivation of the Oedipus complex but

the reinforcement of the physiological sexual drives at puberty furnishes

a strong impetus away from pregenital sexual interests to genital ones

and away from the Oedipus complex to love relationships with persons

of the opposite sex outside the family circle. In other words, adolescence

normally brings with it tendencies toward genital and heterosexual in-

terests and activities. There is also a tendency to reinforce masculine

identifications for the boy and feminine ones for the girl. If the parent

of the same sex has been lost or is unsatisfactory for such purposes, the

adolescent tends to find some other person in his environment with whom

to identify in establishing masculinity or femininity.

If the adolescent's environment is too unfavorable, or if there were too

many difficulties in his earlier development during childhood, the normal

tendency to establish heterosexuality and make suitable masculine or

feminine identifications may be defeated. Then the adolescent may have

to fall back on homosexuality or other infantile sexual satisfactions.

Nunberg also speaks of the adolescent conflict between the reinforced

sexual drives and the super-ego's standards of behavior and sees the

outcome of this conflict within the personality as important for the estab-

lishment of a well integrated personality or of neurotic patterns.

Anna Freud (1937) has elaborated this last point considerably. She

agrees with Nunberg that genital drives tend to predominate in adoles-

ence but she believes that the sexual drives are not the only ones to be

greatly reinforced at puberty. The aggressive impulses and all the other

id-drives are also strengthened and intensified, in her opinion. The in-

crease in quantity and quality of the id-drives threatens the ego with

being overwhelmed by their strength and becoming unable to continue its

function of mediating between the instinctive impulses and the super-

ego's demands based upon moral and ethical standards. For normal

development, the adolescent must find a new balance between these parts

of the personality, the ego must preserve its function of modifying both

the id-drives and the super-ego's demands for acceptable conduct with-

out sacrificing completely either satisfactions for emotional and instinc-

tive needs or all ethical ideals. If the ego surrenders to the id, allowing

the id-drives to obtain complete domination, the outcome would be un-

inhibited efforts to satisfy sexual and other drives ; presumably this un-

controlled attempt at direct gratification of impulses might go far

enough so that it would end in delinquency. If, on the contrary, the ego

yields entirely to the demands of the super-ego and strictly inhibits or

represses all instinctive and emotional drives, rigidity of the personality

22] ADOLESCENT EXPERIENCE 699

would result, with a loss of the flexibility necessary for suitable adapta-

tions to continually changing reality situations. Zilboorg (1937) speaks

of youthful suicide as another possible outcome of these adolescent per-

sonality conflicts.

Anna Freud also discusses adolescent asceticism and intellectualiza-

tion as frequent reactions to the personality conflicts arising during this

period of development. Asceticism is utilized as one of the defenses against

the instinctive and emotional drives, in her opinion. Adolescent intel-

lectualization may be observed in the tendency to debate various abstract

subjects, such as free love versus marriage, revolution versus support of

existing political forms of government, atheism versus religious faith,

etc. These intellectual interests reflect the conflicts between the id-drives

and the super-ego, but Anna Freud points out that they are also an effort

to work through those conflicts and to obtain mastery over the instinctive

and emotional drives without either completely yielding to them or deny-

ing them entirely. Hendrick (1938) suggests that adolescent intellectual-

ization may serve still another purpose by giving intellectual practice

which later can be utilized by the ego in its function of evaluating

reality.

Perhaps this summarization of Freudian theories has given too much

of an "either-or" implication regarding the chances for favorable or un-

favorable outcomes for adolescent personality development. If so, this

would be too great an oversimplification, for asceticism, neurotic symp-

toms, "wild" behavior, etc., may be only transitory reactions, followed by

a better balance and integration within the personality when the peak of

the conflict between id, ego, and super-ego has been passed. Certainly

Anna Freud, Nunberg, Hendrick, and others writing from the Freudian

viewpoint have stressed the normative impetus furnished by biological

maturation at puberty, as well as seeing adolescence as one of the critical

periods in personality development.

Freudian theory has always given due consideration to the sublimation

of the instinctive and emotional drives as a normal aspect of personality

development and it seems important to mention the significance of sub-

limation for adolescence, as well as for the latency period of childhood.

Many observers have noted that an increase of creative activities is often

characteristic of adolescence ; an adolescent phase of interest in literary or

artistic productions followed by a gradual decrease in such interest, is a

fairly common phenomenon. Adolescent stories, poems, drawings, and

paintings very often reflect personality conflicts and are an attempt to

work through those conflicts or master intensified emotional drives, in a

manner similar to that described by Anna Freud in discussing adolescent

intellectualizations. Moreover, as Hendrick said of the intellectual activ-

ities of adolescence, so we may also say of adolescent creativeness, that

the practice it offers in sublimation may be important for later adjust-

ment, for our culture ordinarily requires individuals to live at more or

less sublimated levels and does not always permit direct and full gratifica-

tion of instinctive and emotional drives even in adult life.

7 oo PERSONALITY AND THE BEHAVIOR DISORDERS [22

Adolescence from the Rankian Viewpoint

In a paper read at the National Conference of Social Work (1941),

Hankins has discussed adolescent development from her own experience

and from a background of Rankian theory. This theory starts from an

assumption that the unborn child is part of a physical whole but loses this

wholeness at birth, when he becomes a separate biological organism

instead of a part of the mother's organism, as was the case during em-

bryonic life. But after the biological differentiation that occurs at birth,

the infant is so dependent upon the mother that psychologically he still

is very largely undifferentiated from her and has little awareness of a

self apart from hers. The infant soon begins to become aware of the

fact that he and his mother are two separate individuals, however, and

this brings a sense of loss of the wholeness previously experienced in re-

lation to the mother as embryo and helpless newborn baby. In very early

childhood, therefore, the individual begins efforts to regain a sense of

wholeness or "totality" but the only way this now can be achieved is

through totality in and for himself, by gaining a sense of a self distinct

and different from other persons. First by identification with the mother

and then with other persons, the child takes into himself the material

with which to build up an individual self, but gradually he becomes able

to differentiate himself from those with whom he was earlier identified.

As he becomes less receptive and more self-assertive and self-differen-

tiating, he becomes increasingly aware of his own individuality and ac-

quires a sense of wholeness or totality through the possession of a self

which he can feel is all his own.

At the same time that this self-development is taking place, the child

also must learn to relate himself to others with parts of the self. For

comfortable living, a balance between total action and partial action is

necessary. Adolescence brings both opportunity and necessity to find a

further balance between maintenance of the sense of totality in the self

and relating the self to others, but the latter requires partial action and

hence produces tearfulness of sacrificing too much of the individuality

and totality that has slowly been achieved. From the Rankian view-

point, the sexual drives of adolescence appear as generic forces within

the individual which offer a threat to his independence and sense of self.

The adolescent fears and resists his sexual impulses because they might

dominate him and force him to renounce his capacity to act as a total

self. In our culture, the reconciliation of the generic sexual drives and

individual self-expression lies in a love relationship with another person,

but the adolescent often fears to enter into such a relationship since he

would have to give up total personal control and to accept partial control

from that other person. The adolescent has only just begun to feel

some freedom from the domination of parents and other adults and is far

from ready to give up this glimpse of personal freedom by yielding to

sexual impulses in the form of a love relationship with another indi-

vidual, for to love another is to yield parts of the self to the loved person

22] ADOLESCENT EXPERIENCE 701

and to sacrifice the possibility of independent total action, at least to

some extent.

Hankins suggests that the normal outcome for adolescence would be

through learning that new experiences and relationships may be enrich-

ing to the personality even if they do involve some self-sacrifice. She

further suggests that adolescent asceticism is not explained correctly by

Anna Freud, but is to be understood as a method of maintaining indi-

viduality by denying generic sexual drives or keeping them under strict

control. Hankins also sees sexual promiscuity not as an uninhibited effort

at instinctual gratification but rather as another attempt to preserve the

individual self, since the transitory sexual relationship can be used to

dominate another person through his sexual needs while at the same time

refusing to yield any part of the self, as would be necessary in a real love

relationship.

Mental Disease and Delinquency in Adolescence

With all the emphasis that has been placed upon adolescent insta-

bility and the personality conflicts of adolescence, it might be expected

that psychoses or delinquency would often have their onset at this period

of life. Statistical studies do not confirm this expectation; instead, it

would seem from the available statistics that mental diseases (psychoses)

usually come into the open during the adult life after adolescence, while

delinquency ordinarily begins before adolescence during the childhood

years.

Using the 1930 figures for the population of the country and the

figures for first admissions to mental hospitals in 1933, Landis and Page

(1938) compared the percentage of hospital admissions for certain age

decades with the percentage of the general population in the same age

decades. In 1930, a greater percentage of the general population was in

the age decade from ten to nineteen years than in any age decade above

nineteen years, but the smallest percentage of hospital admissions in

1933 was for the age decade ten to nineteen. Only 5% of the mental

hospital admissions were in the ten to nineteen-year group, while 19.2%

of the general population fell into that age group. Yet for each succeed-

ing age decade, the percentage of state hospital admissions became in-

creasingly larger than the percentage of the population falling into the

same age group. In the 20 to 29-year decade, 17.1% of first admissions

to hospitals compared with 16.9% of the general population ; the dispro-

portion of hospital admissions to population increased with each decade

thereafter.

While these figures indicate that psychoses are not the immediate

outcome of adolescent personality conflicts, they do not negate the

opinion of many psychiatrists that functional mental diseases, such as

dementia praecox (schizophrenia) and the manic-depressive psychoses

have their etiology in childhood and adolescent experiences and develop-

ment. In this connection, it should be noted that these two types of psy-

7 02 PERSONALITY AND THE BEHAVIOR DISORDERS [22

choses, according to both Landis and Page, and Malzberg (1935), ac-

count for most of the state hospital admissions during adolescence and

young adult life. Moreover, studies based on age of admission to state

hospitals undoubtedly tend to underestimate the number of individuals

developing psychoses during adolescence. In clinical experience, when

we see adolescents suffering from a beginning psychosis, we find that

parents are often reluctant to consider hospital care and that hospitaliza-

tion is postponed until it becomes inevitable when the psychotic con j

dition is further advanced.

Hunt (1938) has described a neighborhood group of boys who en^

gaged in sexual perversions and also went through experiences of reli-

gious conversion at revival meetings. A few boys in the same neighbor-

hood attended the revivals but did not engage in the sexual practices ; a

few participated in the latter but not the former. The boys who took part

in both the sexual and religious experiences developed mental disease

later in life, while those sharing in one experience only, did not become

psychotic. Thus, only those members of the neighborhood group who

developed conflicts during adolescence because of the incompatibility

between their sexual behavior and their religious ideals, and carried those

conflicts on into adult life, became mentally ill. The age of onset for

their mental illnesses differed considerably and Hunt suggests that the

differences in age at which they became psychotic probably indicate vari-

ations in their capacity to endure and tolerate conflict before reaching

a breaking point. This suggestion is pertinent to the present discussion,

for the statistics on age of admission for patients in mental hospitals may

mean that psychosis is not an immediate outcome for adolescent person-

ality conflicts in any great number of cases, but do not necessarily mean

that it is not a delayed outcome. Probably a great many persons have

enough capacity to bear conflict so that the conflicts begun during child-

hood and adolescence do not take their full toll in the form of mental

illness until some time afterward in young adult life or even in later

adult years.

Many studies of delinquents have indicated that the childhood environ-

ment is a large factor in the etiology of this behavior ; we only need to

refer in passing to such findings as the large proportion of broken homes

or other extremely unfavorable family situations, neighborhood condi-

tions producing so-called delinquency areas, etc., for these sociological

findings are reported in the chapter on ecology, by Paris. In this chapter,

therefore, it is only necessary tc include the statistical evidence that for

the most part delinquency has its beginnings in childhood, before adoles-

cent experiences can become a determinant.

Investigating the histories of 500 offenders sentenced to a reformatory,

the Gluecks (1930) found that 51 had been in conflict with social au-

thority by the age of ten or younger; 137 by the age of fourteen or

younger ; 393 by the age of sixteen or younger. In the same 500 cases,

45 had their first known arrest by the time they were ten years old;

121 by the age of twelve or earlier; 214 by the age of fourteen or earlier;

22] ADOLESCENT EXPERIENCE 703

297 by the age of sixteen or earlier. Cole (1936) has interpreted data

reported by the Gluecks for 1,000 juvenile court cases, in relation to

adolescence; 31.6% had been brought into court before adolescence;

83.7% had manifested delinquent tendencies before adolescence, even if

not brought to court ; at least 35.7% could have been recognized as delin-

quent by the end of the second grade in school. Less than one-fifth of

these 1,000 children became delinquent during adolescence; more than

four-fifths were delinquent before adolescence and continued delinquent

behavior after becoming adolescent. Healy and Bronner (1936) report

that in 153 intensively studied cases, the first known delinquency oc-

curred at eight years or earlier in 48% and after twelve years in only

22%.

Clinical Material

Many of the statistical studies based on clinical cases indicate that the

parent-child relationship is important for personality and behavior de-

velopment, since a large amount of unfavorable parental relationships

appears in the cases of personality and behavior difficulties coming to

clinics. Most of these reports include a larger proportion of children

than of adolescents and probably should not be referred to in this chapter

limited to a discussion of adolescence, except to remark that unfavorable

relationships between parents and children usually will be carried on into

the adolescent years and increase adolescent difficulties of personality

development.

There is one clinical statistical study concerned entirely with high

school students, which should be mentioned in more detail. McBee

(1935) classified the problems of 328 students seen at a high school

mental hygiene clinic. Since the delinquent and truant groups were

small, the findings with respect to them may be omitted, as may be also

the findings for the groups with problems of scholastic failure and prob-

lems associated with physical handicaps or organic illnesses. The mate-

rial on 102 students with personality problems is most relevant to the

purposes of the present chapter, and may be summarized as follows :

Nearly all the 102 students with personality maladjustments were of

average or above average intelligence ; in this respect they did not differ

greatly from the total student body. McBee considered it significant,

however, that 57% of the mothers and 40% of the fathers were foreign

born, in the 102 cases of personality problems, while only about 30% of

the parents of the total student body were foreign born. There seems to

be some inconsistency in the figures given in two of McBee's tables one

on home situation and another on broken homes but if the lowest

figures are taken, it appears that at least 40% of the 102 students with

personality difficulties were not living in homes with both parents

but in homes broken by the death of one parent or by separation of the

parents. These findings suggest that one factor in the adolescent per-

sonality maladjustments was the friction in the family due to disharmony

704 PERSONALITY AND THE BEHAVIOR DISORDERS [22

between the old-world standards of foreign-born parents and the new-

world standards of the Americanized adolescent sons and daughters.

They also suggest that emotional disturbances over the loss of a parent

who has died or over marital difficulties and separation of parents were

other factors contributing to adolescent difficulties in personality ad-

justments.

Howard (1941) classified the problems presented by 117 college girls,

attempting to distinguish between those which represented a continuance

of adolescent conflicts and maladjustments and other types of problems.

The continuing adolescent difficulties were described as follows : 24 cases

in which interfering family ties were prominent ; 23 cases of anxiety ; 1 1

cases of neurotic depression ; 8 cases of adolescent asceticism and intel-

lectualism; 7 cases of adolescent rebellion against work and routine;

7 cases of masculine identification. Among the 79 girls thus described,

41 also complained of difficulties in adjusting to sexual drives.

In most other reports on the adjustment and personality problems of

college students, no differentiation has been made between problems of

adolescence carried over into young adult life and other types of prob-

lems. Hence the data from other studies of college students cannot be so

definitely related to a discussion of adolescence.

Individual Case Studies

In actual clinical work, the chief interest is in the adolescent as an

individual, with his own particular personal problems, and in helping

him with his efforts to make adjustments and to achieve a better per-

sonality organization. Case reports illustrating a wide variety of adoles-

cent problems are to be found in many of the books and papers included

in the bibliography for this chapter. Other case material is relevant to

the purposes of this chapter in so far as it can be related to the general

and theoretical material previously summarized and can be utilized to

clarify certain points in the preceding discussion.

The tendency toward a change of interests and attitudes at puberty,

indicated by the Stone and Barker studies of premenarcheal and post-

menarcheal girls, may be illustrated by the case of a girl in whom men-

struation was established during the time when she was having regular

interviews with the psychologist. The purpose of these interviews was

to help the girl with emotional conflicts over the loss of her parents and

the necessity of living at a boarding school. This aspect of the case, how-

ever, has little bearing on the present discussion. The material of special

interest is the striking change observed in the girl's interests and activ-

ities as soon as she began to menstruate.

She was first seen at the age of eleven and a half and weekly interviews

with her continued until she was nearly twelve and a half. For some time

in these interviews, she spoke of playing with dolls and taking them to

bed with her and liked to play with dolls or cut out paper dolls while talking

to the psychologist. At the school, she played active outdoor games as well

22] ADOLESCENT EXPERIENCE 705

as playing with her dolls. She displayed little interest in her personal

appearance or dress and was careless about wearing soiled or torn clothing.

She never talked of any plans as to what she might do when she was through

school and must take care of herself.

At the age of twelve she menstruated for the first time. In the next

three months, although no effort was made to redirect her interests and

activities either by the psychologist or by her teachers at school, the fol-

lowing changes occurred. The girl mentioned that she had given away her

dolls and no longer wanted to play with the dolls in the psychologist's office

or to cut out paper dolls during her interviews. At the school she read

romantic fiction in her leisure time instead of continuing to play active

outdoor games. She became very particular about her personal appearance

and the neatness of her clothing; began to curl her hair and to use face

powder and nail polish. She made herself a dress in sewing class at school

although she had previously expressed some distaste for sewing. She be-

came very much concerned over plans for vocational preparation and began

to wo r ry over what high school course to select, although choice of a high

school course was not required until ninth grade and she was still in seventh

grade.

The case of a fourteen-year-old boy offers an illustration of adolescent

efforts to adjust to the reinforced sexual drives of puberty and to estab-

lish masculinity.

The boy was seen just after he had written a note to a young woman,

making definite sexual advances. In his first interviews he talked almost

continuously about sexual questions, expressing intense curiosity about

anatomical differences between the two sexes and wanting to know how

babies were conceived and born. It is difficult to believe that any fourteen-

year-old-boy actually could be as uninformed as this boy seemed when he

advanced various theories that might answer his questions; the possibility

that babies came out of the breast or navel of a woman is a sample of his

attempts to elucidate the mysteries of sex and birth. His questions and his

explanations were those usually characteristic of a five-year-old and sug-

gest the revival of early childhood curiosity and fantasies about sex and

birth, mentioned in psychoanalytic theories as a common manifestation at

adolescence.

After partially exhausting these sexual interests, the boy began to talk

about his relationship with his father, who had died a few years previously.

He told of the satisfying companionship with his father and how much

he had missed him since his death. A little later, he described his activities

with a gang of boys slightly older than himself. In the year of his associa-

tion with these boys, he had heard many stories about sexual relationships

between men and women and had experimented considerably with masturba^

tion. These boys had talked about the young woman to whom he had sent

the note, describing her as sexually promiscuous, and had suggested his

writing to her, inviting her to have sexual relationships with him.

The boy showed guilty feelings over his sexual activities in the gang

when he became anxious about the possibility that masturbation might have

injured him either physically or mentally and when he said that if his father

had still been living, he would never have allowed him to go with such bad

boys. On the other hand, he doubted whether he would have started to go

706 PERSONALITY AND THE BEHAVIOR DISORDERS [22

with the gang if he had not been so lonely after his father died. At this

point he was able to see that in joining the gang of boys he was not only

attracted by their conversation about sex but also was seeking some mascu-

line companionship to replace that lost through the death of his father.

Shortly afterward, the boy began to talk admiringly of a man who was

his teacher in Sunday school. He became very friendly with this man and

told of going on fishing trips with him as he once had done with his own

father. This man also helped him to make model airplanes, and lent him

books about animal breeding. To a casual question about his gang, the boy

answered that he had not seen much of those boys recently and added that

going around with them had only gotten him into trouble. A little later,

he said that he had a girl friend at school, mentioned inviting her to go to

the movies and reported that she had accepted.

It seemed evident that the boy had now begun to sublimate his sexual

interests first through his studies of animal breeding and then through

social activities with a girl friend. In the Sunday school teacher, he had

found a suitable substitute for the father whom he had lost and had been

able to identify with this father substitute in establishing his own masculine

interests.

The extent to which parental attitudes can interfere with adolescent

personality development is shown very clearly in such an extreme case

as that of a seventeen-year-old girl whose teachers were concerned be-

cause she had no friends of her own age and took no part in the school

social functions. Although well developed physically for her age, the girl

appeared for her interviews dressed in a childish style. Her conversation

readily explained her attitude toward her classmates and their social

activities.

She said that she would not go around with the other girls because they

used cosmetics and were crazy about boys. Her mother had told her that

she was not to use rouge and lipstick and make herself look like a prostitute.

Her mother had also told her what dirty beasts men and boys were. She

hated boys and men and couldn't stand the other girls' silly talk about their

boy friends. She would not go to school social affairs because if she did

she would be supposed to talk with the boys, as well as with the other girls.

She had never learned to dance and did not wish to learn to dance. It was

only because they liked to be with boys that the other girls had learned.

The girl saw no reason for her teachers wanting her to see a psycholo-

gist. Her mother also did not consider it necessary. Indeed, her mother

made it quite clear that she resented the teachers wishing the girl to make

friends and attend social functions at the school. She spoke disapprovingly

of her daughter's classmates and said that she had brought up her daughter

so that she would not be boy crazy. If the teachers were going to encourage

girls to be boy crazy, she would take her daughter out of school.

Besides illustrating the influence of parental attitudes upon adolescent

development, this case might also be used to illustrate strict super-ego

control and denial of normal instinctive drives, resulting in a rigidity of

personality one of the possibilities for outcome of adolescent develop-

ment described by Anna Freud. The Rankian viewpoint probably would

22] ADOLESCENT EXPERIENCE 707

stress still another aspect of the girl's development and would see her as

having failed to achieve any differentiation from her mother and to estab-

lish any independent self of her own.

An illustration of adolescent literary productions as efforts to work

through conflict rather than expressions of unusual literary talent,

appears in the following poems written by a sixteen-year-old girl after

the termination of an extra-marital sexual relationship. They show very

clearly her effort to forget her lover and her remorse and guilt ovei

having gone counter to the dictates of her moral ideals, with momentary

thoughts of suicide as a way out of conflict and grief over lost love.

FORGETTING

I thought that I had forgotten

All the sorrow caused by you.

I hoped that I could forget

'Tis the only thing for me to do.

Oh, I hoped that I had forgotten

The man who broke my heart,

But a song, a song that you sang,

Tears my very soul apart;

The tears fill my eyes, I remember

Your voice as you sang it to me;

Oh, I long for you wildly, my dearest,

My darling, please come back to me.

THE REACTION OF CONVENTIONS

Buried in the secret heart

Is an unknown, bitter dread

Of things that one is forced to do

Though longing to do the opposite instead.

Remorsefulness turns into hate,

At last wild rage breaks forth;

The things we once were forced to do,

We'll always hate, of course.

MY TROPICAL ISLE

Lost on a tropical island

In a lonely expanse of sea,

To some might be a misfortune,

But I wish it could happen to me.

I could sleep 'neath the southern moonlight,

Undisturbed 'till I chose to awake.

Should I choose to sleep on forever

What difference would it make?

Should I choose to sleep on forever

What would there be to fear?

In death I might find peace

With no one to interfere.

7 o8 PERSONALITY AND THE BEHAVIOR DISORDERS [22

The last illustration is the case of a girl who was finally able to achieve

a healthy integration of personality after first resorting to neurotic illness

and asceticism as transitory attempts to solve her adolescent conflicts.

She was first seen at the age of fifteen, shortly after she had begun to

complain of inability to recite, because of choking sensations in her throat,

when called upon in the classroom. Repeated medical examinations were

negative, indicating that her symptoms were of a neurotic nature. Men-

struation had been established at least a year before the onset of the

difficulty in reciting.

Although the girl appeared to talk very freely in her first interviews,

there was nothing in what she said that seemed to have any bearing upon

the development of her symptoms. She never complained of the choking

sensations or was unable to talk when with the psychologist. After several

interviews had thrown no light on her difficulty in reciting, a conference

with the school principal and school nurse was requested, in the hope that

further information from them might be of help. They confirmed their

previous reports of the giiTs superior rating on intelligence tests and good

standing in her school work. They could think of nothing unusual in the

girl's school situation prior to the onset of the symptoms except that one

of her friends had withdrawn from school because she was about to have

an illegitimate child.

In the next interview with the girl, she was asked about this friend.

When she saw that the psychologist knew what had happened, she felt free

to tell how her friend had confided in her, but had exacted a promise that

the confidence be kept a secret. The girl had not thought about this secret

when talking with the psychologist, she said, but at school she often thought

of it, wondered if any of the other girls knew why her friend had left

school, but could not ask them because of her promise. When asked whether

she might have feared to talk in class, lest somehow she break her promise

and betray her friend's confidence, she answered, "Well, it won't be a secret

much longer; the baby will be here in another week or two." The friend's

baby was born within that time. The girl then began to recite in class and

no longer had choking sensations in her throat that prevented her from

doing so.

However, it seemed that these symptoms had been replaced by another

set, for apparently the girl began to withdraw from social contacts with

the other girls and boys at school. She spoke of this in her interviews. She

had been wondering how her friend got into trouble, she said, and thought

her friend must have been too much interested in boys. But the other girls

were just the same, always flirting with the boys. So she had decided to

keep away from them and not get into their bad habits. She had wondered

which boy had induced her friend to "go too far"; her friend had refused

to tell her the boy's name. Since she didn't know which boys at school

could be trusted, she thought it best to keep away from all of them.

This girl's mother had died when the girl was about thirteen years old.

She said that she knew how her mother would have felt if anything should

happen to her such as had happened to her friend. She quoted her mother's

dying words to her "Be a good girl" and her own promise, "I will,

mother." Her mother had always liked to have her go to church, sing

22] ADOLESCENT EXPERIENCE yog

hymns, and study hard so as to get good school reports. Since thinking so

much about her mother recently, she did not feel like singing popular songs

but only hymns. She had decided to spend her time on her school work,

keep away from the boys and girls at school, and stay out of trouble. She

also had decided to become a school teacher, so she had to work hard on

that account, too.

It was some time before she dared to admit that, like the other girls,

she had formerly been interested in boys and wanted dates with them.

Once she was able to recall these attitudes, she could say that there was

no need for her to be so worried, it was no sign that she would get into

trouble just because her friend had done so. Shortly afterward, it was

reported that she had resumed her usual social relationships with the other

students at school. The case was closed with the girl seeming free from

neurotic symptoms and anxiety, enjoying ordinary social contacts with girls

and boys at school, but not making dates with boys and still planning to be

a teacher.

About a year later, she came for a visit, to let the psychologist know

that she had not had any recurrence of illness symptoms. At this time, she

announced that she had a "steady" boy friend who was eighteen years old

and had secured a good job since he graduated from high school. He

wanted her to marry him as soon as she was through high school, she said,

and she was planning to do so. She would be eighteen when she finished

high school and she thought that would be old enough to marry, for her

mother had married her father just before she was eighteen. Since she

was no longer planning to teach, she had dropped some of her college

preparatory courses and replaced them by domestic science courses which

would help her to become a good wife and mother.

It is not difficult to interpret this case in terms of Anna Freud's de-

scription of the adolescent personality conflict. Probably the girl's knowl-

edge of her friend's behavior precipitated a severe inner conflict, since it

may have stimulated her own curiosity and desires while at the same

time emphasizing the dangers of heterosexual interests. In talking of

the possibility that she, like her friend, might "go too far" with boys

she was expressing her fear of her own impulses and of becoming too

free in behavior. When she recalled her mother's teachings and dying

admonition, she may well have been seeking a support that would help

her to feel secure in her ability to control her sexual impulses. The

memory of a promise to a dying person would be an especially powerful

reinforcement for her own moral ideals because the tendency to regard

such promises as sacred invests them with some of the qualities of a

magical protective charm.

To have discussed her friend's trouble would have required talking

about sex matters, as well as betraying the friend's confidence. Pre-

sumably she was fearful of conversation along this line as well as tempted

to initiate it and this conflict was disguised in the symptoms that kept her

from reciting in class. In giving up these symptoms, she mobilized the

memories of her dead mother's moral standards to reinforce her own

710 PERSONALITY AND THE BEHAVIOR DISORDERS [22

ideals of conduct. But she overdid this for a time, carrying it to the

extent of asceticism and extreme absorption in intellectual interests. The

asceticism could be partly relaxed when she realized that her friend's be-

havior need not influence her own conduct and could be entirely dis-

carded when the prospect of an early marriage promised a satisfying

emotional life in harmony with her ethical ideals and with the realities

of social conventions.

Conclusion

From whatever viewpoint adolescence is regarded, it seems to be

agreed, with but few exceptions, that the changes in the physiological

organism that take place at puberty result in reinforcement of hetero-

sexual drives and of strivings for independence and personal responsi-

bility. These drives have been in existence during the earlier years of

childhood but become much stronger than ever before at adolescence.

Whether aggression is also reinforced at puberty or only increases then

in reaction to a cultural environment which is frustrating to the adoles^

cent's desires for satisfaction of heterosexual drives and drives toward

personal independence seems to be a question on which there is somewhat

less agreement.

While there is plenty of evidence indicating that parent-child rela-

tionships may be favorable or unfavorable to personality development, it

seems doubtful that this situation is peculiar to adolescent development,

for favorable or unfavorable parent-child relationships are more likely to

begin early and continue into adolescence, rather than first making their

appearance only at this age. Perhaps we should say that the background

of family relationships may bring the child to adolescence either well

prepared to continue previously good development or badly prepared to

meet the necessities for individual and social readjustments that arise at

puberty.

There have been two differing viewpoints concerning adolescent con-

flicts. One sees the adolescent as in conflict with social authority vested

in parents or other adults. The other viewpoint on adolescent conflicts

emphasizes those within the individual's own personality and sees the

external family and social influences as favorable or unfavorable for a

healthy outcome of these inner personality conflicts.

Experimental investigations seem to confirm the psychoanalytic theory

that the normal growth and maturation processes of adolescence exert

their force on the side of a better integration of the personality and the

establishment of heterosexuality and may even be strong enough to over-

come previous childhood developmental difficulties or environmental

obstacles to heterosexual adjustments and personality organization. But

in spite of the impetus toward normal personality development, there

may be less desirable outcomes for adolescent personality conflicts. There

is the possibility of the adolescent's renouncing the drives toward more

mature emotional satisfactions with such personality losses as damage to

22] ADOLESCENT EXPERIENCE 711

the capacity for flexible adjustments to reality. There are also the pos-

sibilities of such outcomes of adolescent experience as delinquency,

neurosis, psychosis, or even suicide.

Aichhorn (1935) has distinguished between two types of delinquency,

one developing over a long period of time, the other manifested as a

sudden outbreak in a previously nondelinquent individual. Statistical

studies in this country suggest that the latter type is more rare than the

former, for these statistics indicate that delinquent conduct begins in

childhood much more frequently than during adolescence. Perhaps we

may conclude that while delinquency may be an outcome of adolescent

conflicts, even if it has not been characteristic of the individual in child-

hood, it is a more probable outcome if it has previously been the reaction

to earlier childhood conflicts or other childhood experiences.

While the facts regarding psychosis as an outcome for adolescent

development are somewhat less clear, it seems likely that they may be

almost the opposite of those with respect to delinquency. Instead of a

childhood or adolescent onset of psychosis, there probably is more apt to

be a prolongation of severe emotional conflicts arising in these earlier

stages of development, resulting in an onset of psychosis later on in adult

life, when the limit of the individual's capacity to tolerate conflict has

been reached. If, as Hunt (1938) suggests, there may be considerable

variation in the capacity for toleration of conflict, a large proportion of

the mental illness having its onset in adult years is actually a delayed out-

come for childhood and adolescent experience and development. Many

psychiatrists have stressed childhood and adolescent experience as sig-

nificant in the etiology of the functional psychoses. Psychoanalytic work

with neurotic patients has shown that most of the neurotic illness which

appears in adult patients had its etiology in childhood and adolescent

experience and represents a delayed outcome for childhood and adolescent

personality conflicts even when it has not been openly evident as the

immediate outcome during or directly after adolescence. Suicide as a way

out of conflict often is postponed until the individual's capacity to endure

conflict is exhausted, rather than being to any great extent an immediate

outcome for adolescent conflicts.

Hall once spoke of adolescence as a kind of rebirth experience. Per-

haps this is a figurative way of saying that the impetus toward psycho-

logical maturity furnished by the intensified emotional and instinctive

drives at puberty normally is powerful enough to so modify and enrich

the personality that an individual often seems like a different person after

adolescence than he was ever before. But it also is true that the experi-

ences of infancy and childhood or unfortunate environmental influences

sometimes may be as strong or even stronger determinants for person-

ality and behavior, may prevent psychological maturation from following

upon biological maturation, and may interfere with the adolescent's util-

ization of the opportunity for modification and enrichment of the per-

sonality.

712 PERSONALITY AND THE BEHAVIOR DISORDERS [22

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Chapter 23

CULTURAL DETERMINANTS OF PERSONALITY

By GREGORY BATESON, M.A.

WHEN WE THINK OF THE MULTITUDINOUS VARIETY of the special cases

of human behavior, when we watch a native of New Guinea doing this,

a native of New York doing that, a native of Samoa doing something

else, we are faced, as scientists, with a very serious difficulty the diffi-

culty of trying to imagine what order of general statement will cover

these very diverse phenomena, and many different scientific approaches

have been devised in the effort to solve this problem. In this book we

have, for example, the theories which have been devised by physiologists

and neurologists, and other theories devised by those who studied the

phenomena of experimental learning; other theories, again, devised by

those who studied mental pathology, and so on. The basic presumption

of such a symposium as this is that these various theories, no matter how

diverse, are not necessarily mutually contradictory ; that there is a possi-

bility of translating, in the end, from the theories devised by psycho-

analysts into terms of the theories derived from physiology; and those

again into terms derived from experimental learning.

In spite of this great hope of ultimate translation, we have the fact

that the theories have originated among workers using different kinds

of data. This chapter is intended to give some general statement of the

theories which have been reached by those who worked with a very

curious kind of data, namely, observations upon preliterate people, and

we shall endeavor to build up this picture inductively, starting from the

various different threads in cultural anthropological work. But before

we do this, it is necessary to make one negative statement about "cul-

tural determinism," which needs to be kept clearly in the mind of the

reader. We do not suggest that culture fully "determines" anything.

The phrase "economic determinism" has, unfortunately, become a slogan

of those who believe that economic "factors" are more "basic" than, per-

haps, any others. In the opinion of the writer, this view is disastrous,

and I should like to see substituted for it the notion that, at best, an eco-

nomic approach to human behavior is rewarding, perhaps very reward-

ing, for the insight which it gives. This is a very different position, and

implies that economics is something that scientists do, not something that

exists in the world as a determinative or "basic" cause. Similarly, we

shall use the phrase "cultural determinism" to imply that "culture" is an

abstraction a ready label for a point of view built up by a number of

714

23] CULTURAL DETERMINANTS OF PERSONALITY 715

scientists a point of view from which those scientists have achieved

some insight.

Origin of the Concept of Cultural Determinism

The early days of anthropology were concerned chiefly with the busi-

ness of description, and especially the early anthropologists were struck

by outstanding bizarre features of the cultures which they studied. In

their attempts to generalize, they were concerned chiefly to find identities

or close similarities between phenomena in one place and phenomena in

another. This is perhaps always the first step in a new science the

search, not for an abstract regularity, but for a concrete, episodic simi-

larity between what occurs here and what occurs elsewhere ; or between

something which occurs now and something which occurs at some other'

time. Correspondingly, the theories of these early anthropologists were

chiefly oriented to explaining such similarities, and naturally, since the

similarities searched for were episodic, the type of theory which was

devised was episodic or historical theory. Controversy raged, for ex-

ample, between those who believed that resemblance between far-sepa-

rated cultures ought to be accounted for in terms of similar evolutionary

process and those others who believed that all such resemblance could

only be accounted for by processes of cultural contact and diffusion. In

the latter half of the nineteenth century and the beginning of the twen-

tieth, cultural anthropologists were very seriously influenced by ways of

thinking which they believed were in line with the Darwinian theory of

evolution, and indeed it is perhaps fair to blame upon Darwin some of

the errors of this period in anthropology. The Darwinian theory, in the

form in which it was popularized, gave great emphasis to problems of

origin. It was assumed that the way to account for some biological phe-

nomenon especially for some anatomical detail was to seek for the

philogenic origin of that anatomical detail. Similarly, the anthropologists

concerned themselves with looking for cultural philogenies, and their

controversies were parochial squabbles within the general assumption

that philogeny was the answer.

In the biological field, the ways of thought have changed very much

since 1900. Biologists have focused more and more upon the processes

of evolutionary change and less and less upon the actual history or philo-

genic "tree" of any given species. In place of philogeny, biologists now-

adays talk about genetics and growth. The same change has been taking

place in the field of cultural anthropology. We may have lagged a bit

behind the biologists, but the direction of change in our ways of thinking

has been the same. Nowadays, in place of arguing points of cultural

philogeny, we discuss the fine details of cultural change, and still more

the fine details of internal organization within a culture at a given time.

We have developed a sort of cultural "physiology" in place of the 1 former

groping after isolated details of cultural anatomy, and a sort of cultural

"genetics" in place of the former cultural philogeny. It is this sort of

716 PERSONALITY AND THE BEHAVIOR DISORDERS [23

cultural "genetics" and cultural "physiology" which I have tried to sum

up with the phrase "cultural determinism."

The basic shift in our ways of thinking, from this episodic-historical

approach which looks for similarities toward a more orthodox scientific

approach which looks for regularities in human behavior, has taken place

gradually over the last 20 years, and those who contributed most to the

shift often scarcely realized what order of contribution they were making.

The shift from one approach to another means that, in place of investi-

gating one set of variables, we turn to another set, and the first step was,

perhaps, the establishment by Boas (1938) of the concept of "culture

area," which enabled us to dismiss one set of variables and to start pay-

ing attention to others. According to this theory, it is possible to delimit

areas within which so much contact has occurred between the various

cultures that every one of the cultures in the area can be presumed to

have had access by contact to every one of the principal cultural motifs

which occur in the area. The delimitation of these areas is done by a

careful study of the resemblances between the neighboring cultures and

is oriented to testing the bare fact of their relationship rather than to any

sort of speculative reconstruction of their history. This theory, when

it appeared, was regarded as a historical approach to culture, and the

preliminary inspection of the cultures in order to determine whether they

constituted such a "culture area" and to determine the limits of the area

was, in fact, historical. The theory was safe against historical attack

because of this preliminary spade work, but the implicit rider that we

could say of any given culture : "this culture or this community has had

access, by way of diffusion, to all the main motifs current in this area"

set us free to think about differences between cultures within such a

cultural area. We could dismiss the problem of diffusion within a gen-

eral "other things being equal" clause and proceed to investigate the

cultures in terms of variables other than the episodic-historical details of

diffusion and contact. 1

When we looked at two neighboring cultures, say the Zuni pueblos

and the Indians of the Southwest, we could stop asking "What similar-

ities are there which show that these two cultures are related ?" because

this question had been answered by the preliminary spade work with a

general affirmative "Yes, the two cultures are related." And we could

go on to ask : "Why, then, is the one so very different from the other ?"

and we could try to reduce these differences to generalizations, e.g., by

showing that the internal emphases of Zuni imply so much dislike of loss

of self-control that, no matter how much contact that culture might have

with neighboring tribes who base religious cults on the use of the peyote

drug or with Europeans who base conviviality on the use of alcohol, the

1 In this connection, there is an interesting polemic book (Radin, 1933) in which

the author attacks Boas for not being a historian, without realizing the implications

for further and more scientific development of anthropological theory which are

implicit in Boas' break-away from conventional historical thinking. See also Kroc-

ber (1939).

23] CULTURAL DETERMINANTS OF PERSONALITY 717

Zuni will at most only adopt extremely denatured versions of these cul-

tural traits.

A second trend in modern anthropological thinking, almost as impor-

tant as the escape from the episodic and historical, has been the gradual

recognition of the fallacy of "misplaced concreteness" (Whitehead,

1920), and this recognition came, not from epistemology, but from

careful factual demonstration that theories which ascribed causal effec-

tiveness to "religion," "geography," "language," and the like, would not

fit the facts. Boas (1938) again was a leader in this discovery. He

showed that the family of language which a people has does not deter-

mine other aspects of their culture; that the geographic circumstances

under which they live similarly do not determine the other aspects of

their culture, and so on. In fact, Boas first freed us from examining

two unprofitable sets of variables, and then went on to demonstrate that

certain other variables were not profitable subjects of inquiry.

Overlapping with the main period of Boas' work, there were other

anthropologists similarly engaged in developing a nonhistofical and

abstract approach to the phenomena of culture. Malinowski (1927a),

with a team of well-trained, careful field workers, showed that the be-

havior patterns in any community formed an interlocking, interdependent

unity ; that the "culture" of any people is not to be seen as a set of parts,

each separately investigable, but rather that we should see the whole mass

of behavior and artifacts and geographical circumstances as an interlock-

ing functional system, such that, if we started from, say, the food-

getting behavior the system of agriculture, hunting, fishing, and the

rest and examined that system carefully, we should find that the func-

tioning the effective, continual working of the agricultural system

interlocks at every step with the religion of the people, with their lan-

guage, with their magic, with the geographic circumstances of their life,

etc., and, similarly, that their religion interlocks with all other phases

of their behavior; their economics likewise; and their kinship likewise.

Malinowski, in fact, laid a basis for an organismic approach to cultural

phenomena. While Boas had demonstrated that language is not a cause

of religion or magic, Malinowski demonstrated that everything in a cul-

tural system was, if not a cause, at any rate a necessary condition for

everything else. He showed that, in describing a culture, it was possible

to start with any institutional category of behavior and from that to work

outwards in ever-widening circles of relevance, until the whole cultural

system appears as relevant background for the particular set of data

from which we started.

While Malinowski and his fellow workers were engaged in demon-

strating the enormous complexity and mutual interdependence of all the

parts of a culture, working out, like a fine patch-work quilt, the con-

tinuity and ramifications of all these relationships, Radcliffe-Brown

(1931, 1940) approached the problem from a different angle. He ac-

cepted, as a matter of course, this enormous interdependence within a

culture and regarded the system of behavior in any community as or-

7i8 PERSONALITY AND THE BEHAVIOR DISORDERS [23

ganic in this sense. Then he went on to ask : "What is the bony struc-

ture, what are the salient features of this fine, intricate design?" And

his answer was what he called "social structure." Running through the

whole variety of serious anthropological field work from the time of

Morgan (1871) to that of Radcliffe-Brown, there was a very strong

emphasis upon the study of the kinship systems of preliterate peoples,

and these very profound and conspicuous differences between one cul-

tural system and another had stimulated a very wide variety of specu-

lation. The data were then interpreted in evolutionary terms. The pecu-

liarities of differentiation between mother's brother and father's brother

were regarded as symptoms of a former matriarchy. The same pecu-

liarities of preliterate cultures have also been interpreted by diffusion

theories. When Radcliffe-Brown was working, the central theme, the

central problem of ethnography, was kinship. Thus, Radcliffe-Brown's

work developed as a study of the interrelationship between kinship struc-

ture and what he called "social structure." By "social structure" he meant

the system of subgroups clans, moieties, age-grades, factions, classes,

castes, and the like, in the community. Radcliffe-Brown's classical work

was done on the Australian tribes, and he succeeded in demonstrating

the functional interplay between the totemic system and the highly com-

plex system of behavior roles towards various kin. The totemic system

is unilateral and "closed," which meant that the position of any given

relative say, a mother's brother, or a father's sister's husband in the

totemic system, is fixed relative to ego, so that all ego's brothers-in-law

are necessarily of the same generation and the same totemic group*

There is not space to go into the fine details of the Australian system.

Basically, if we consider only two exogamous divisions of the community,

e.g., Eagle Hawk and Crow, with membership determined either by

matrilineal or patrilineal descent, it is clear that if everybody obeys the

rule of exogamy, every Eagle Hawk man will have relations-in-law in

the Crow group and, even before his marriage, he might logically

classify all Crow people together as "potential relatives-in-law." Aus-

tralian systems have carried this principle much further by superposing

more dichotomous divisions which define generations, as well as lineal

descent, until it is possible for every individual to classify all the other

people in the community by equating subgroup membership with poten-'

tial kinship to himself.

Such a system could be analyzed as working on two levels of abstrac^

tion. We have first the enjoined behavior patterns between kin, e.g.,

between wife's brother in Eagle Hawk and sister's husband in Crow;

and, second, the whole symbolism of myth and ceremony which defines

the major group relationship between Eagle Hawk and Crow.

Radcliffe-Brown was concerned to show that the psychological pre-

sumptions within the family the patterns of behavior between man and

wife, between parent and child were related to the whole pattern of this

totemic system, which also governs the pattern of behavior of clan

members.

23] CULTURAL DETERMINANTS OF PERSONALITY 719

The clans and other subdivisions of an Australian tribe are parts of a

very complex system of opposition and allegiance. The ambivalent ten-

sions which are culturally induced between affinal relatives are expressed

again in the relationship between groups which are potentially related by

affinal ties, and the whole functioning of the society depends upon these

ambivalences and the nice balance between positive and negative com-

ponents of hostility and love (just as our own society depends, in a

laissez-jaire period, upon nice balance between competition and cooper-

ation, production and consumption, etc.). Thus, Radcliffe-Brown's work

led, finally, to some general notion of how opposition and allegiance can

be balanced against each other in a stable community, and this work of

Radcliffe-Brown's was perhaps the first push which deflected the study

of culture and society towards a study of psychology. 2 He did not him-

self regard his work as psychological, but implicit in it were assumptions

about the human personality, about the psychological nature of maleness

and femaleness, parenthood and childhood, opposition and allegiance,

love and hate, which were a first step towards that later development in

cultural anthropology which has diverted more and more attention to

the tracing of the characterological aspects of human behavior. 3

In Radcliffe-Brown's work there is still an assumption that peoples

are psychologically alike, that there are certain basic psychological traits

within individuals. The task of the anthropologist was to ask about the

structure and the functioning of human society, "other things being

equal" ; and within this phrase "other things being equal" was a pre-

sumption that human personality is, in some measure, constant.

The next great change in anthropological approach came with the

attempt to explore yet other variables. It was demonstrated that human

personality is not constant, and this was accomplished largely under the

influence of Boas' students, Ruth Benedict (1934a) and Margaret Mead

(1928a). The latter went to Samoa to study the phenomena of adoles-

cence at the behavioral level. It had been tacitly assumed that the psy-

chological impact of puberty "naturally" caused behavior to be intense

and erratic during the period of adjustment to the new physiological

equilibrium. It followed from this assumption that, if human character

and human physiology were essentially alike the world over, we ought

to expect a similar period of maladjustment to occur in all cultures. Mar-

garet Mead showed, however (1928a), that this was not true of Samoa,

and, further, that the smooth, easy adjustment of the Samoan adolescent

could be referred to peculiarities of the Samoan family organization.

Whereas in Western cultures family organization is such that very

intense ties are established between the child and one or two adults, in

Samoa the ties of affection are slighter and are diffused over a large num-

2 It is difficult, in this connection, to estimate the contributions of Radcliffe-

Brown's teacher, W. H. R. Rivers. Rivers was originally a psychologist and

physiologist, but later became a historically-minded anthropologist. (1923)

3 For further development of Radcliffe-Brown's approach, see Warner (1941),

and Dollard (1937).

7 20 PERSONALITY AND THE BEHAVIOR DISORDERS [23

her of adults and child nurses. The capacity for intense emotional be-

havior is, in fact, a variable which depends on the cultural milieu.

Since that time, cultural anthropology has devoted itself more and

more to unravelling the very complex problems which arise when we

regard as variable not only the whole structure of social groupings, the

whole system of behavior, but also, as equally variable, the human indi-

vidual who exhibits these various forms of behavior.

This research into problems of culture and human behavior has devel-

oped along many different lines, all of them ultimately contributing one

to another, but as yet imperfectly synthesized together. And since this

synthesis is still not achieved, it will be necessary for us to consider each

one of these lines separately.

Typology and Psychiatric Syndromes

For all anthropologists who regard personality as a variable which

must be taken into account, the crucial technical problem is that of de-

scribing the personality. It is no use to recognize a variable until salt can

be put upon its tail. The problem of handling a new variable, or rather

such a complex of variables as is denoted by the word "personality," at

once forces us to try to find either numerical statements dimensions

which can be measured in terms of which personality can be evaluated,

or failing such a quantitative approach, we must develop adjectives which

will describe personality. It is natural, therefore, that anthropology has

turned to psychology, and especially to those schools of psychology which

have tried to define or to discriminate different types of personality. The

earliest work on these lines was done by Seligman (1931), who used the

typology suggested by Jung, of "introvert" and "extravert" types of

personality. Seligman attempted to describe cultures according to

whether they produced, in the individuals, a more introvert or a more

extravert personality structure.

Seligman's work was very little followed up by other psychologists,

and the next major attempt to describe culture in terms of personality

types was made by Ruth Benedict (1934a). Benedict was stimulated,

not by Jung, but rather by the Dilthey and Spengler school of historians.

She attempted to apply the "Apollonian" and "Dionysian" dichotomy 4

4 Benedict does not follow Nietzsche in the finer details of his description of

this typology. The sense in which she uses the terms "Appolonian" and "Diony-

sian" can best be conveyed in her words : "The Dionysian pursues them (the values

of existence) through the 'annihilation of the ordinary bounds and limits of exist-

ence ; he seeks to attain in his most valued moments escape from the boundaries

imposed upon him by his five senses, to break through into another order of experi-

ence. The desire of the Dionysian, in ^ personal experience or in ritual, is to press

through it toward a certain psychological state, to achieve excess. . . . The Apol-

lonian distrusts all this, and has often very little idea of the nature of such expe-

riences. He finds means to outlaw them from his conscious life. He 'knows but

one law, measure in the Hellenic sense.' He keeps the middle of the road, stays

within the known map, does not meddle with disruptive psychological states. In

Nietzsche's fine phrase, even in the exaltation of the dance he 'remains what he is.

and retains his civic name.' "

23] CULTURAL DETERMINANTS OF PERSONALITY 721

to the contrast between the Zuni, a quiet Apollonian group in the south-

west pueblo, and two groups of violently Dionysian people, the Plains

Indians and the Mexican Penitentes, with whom the Zuni were in con-

tact. It is significant that this technique of describing cultural contrast

was most successful in Benedict's hands, when applied to cultures

which were actually in contact. She was able to show, for example, that

a very high valuation was placed upon various forms of dissociated ex-

citement by the Plains Indians and the Penitentes. The Plains Indians

achieve mystic experience when seeking for a vision either through

drastic self-torture or self-repression ; or they may achieve it by the use

of drugs. Among the Zuni all these things were either absent, or more

significantly if present, were practiced in such a way that they no longer

had any Dionysiac quality. Where the Plains Indians use peyote, a drug,

for the achievement of a high degree of disassociation, the Zuni, with the

same drug, living close to the area where peyote is obtained, have never

accepted the peyote cult as part of their religious practices, with the ex-

ception of one, small, deviant group. Similarly, the Zuni have resisted

alcohol, to which every other group of American Indians has, to some

extent, succumbed. In general, where the Plains Indians seek for ecstasy,

for the extremes of religious experience, the Zuni practice their religion

with decorum and precision. Their dancing is exact, a following of a

careful pattern; it is not ecstatic. Benedict was able to follow this

contrast through the whole gamut of Zuni and Plains Indian cultures,

and to show that these cultures had consistently specialized in these par-

ticular forms of expression in all their fields and institutions.

In addition to using this dichotomy, Benedict (1934a) also used con-

cepts derived from psychiatry. She analyzed two cultures, that of Dobu

in the Western Pacific, and that of the Kwakiutl in the Northwest of

America, and showed how paranoidal suspicion runs through Dobuan

culture, while a more megalomaniac paranoidal tendency is characteristic

of the Northwest.

This use of terminology derived from psychiatry raises at once cer-

tain problems and difficulties. We, in Western civilization, regard para-

noidal trends as pathological, and our picture of the paranoiac is of a

deviant living among other people who are not compelled strongly by

paranoia. Benedict's picture of Dobu or of the Northwest is of a

community in which paranoidal trends are normally developed in all, or

in a great majority of individuals. The norms of these cultures are only

understandable if we suppose that these trends are either present in all

individuals or in so many individuals that the trends appear as the

normal stuff of social life. In such a community, the paranoidal con-

structs, instead of being the illusions of a few, become the knowledge and

vision the correct assumptions of the many. The paranoidal sus-

picion which every Dobuan has for every other Dobuan is not an unreal

figment; it is a legitimate generalization from his experience that the

other Dobuan is out to do him in, to beat him in one way or another

to sorcerize him or to steal his yams by magical attack on his garden.

722 PERSONALITY AND THE BEHAVIOR DISORDERS [23

So that while, to us, the term "paranoid" is descriptive of a relationship

to other nonparanoid individuals, the term as applied to the Dobuans

refers to relationships between paranoid individuals.

This raises in very serious form the problem of cultural deviance, and

Benedict's (1934b) contribution to this problem is to point out that de-

viance is a culturally relative phenomenon that a character structuie

which is normal among us may be deviant among the Kwakiutl or the

Dobuans, while a structure which is normal and highly respected among

them would be looked on as dangerous and disruptive in our community.

This typological approach to cultures has been criticized on the lines

that, presuming some degree of standardization, it makes no allowance

for deviance. To this type of criticism, the reply is, first, that the term

"deviance" implies standardization ; and, second, that deviance is allowed

for and expected to occur in all cultures, though it is not expected that

deviance will occur in the same directions in all cultures. Indeed, if

similar distribution of sorts and frequency of deviance in all cultures

could be demonstrated, the whole theoretical approach would have to be

abandoned. Such demonstration has, however, not been achieved. Some

work has gone into statistical study of the frequency of various forms

of psychopathology in different parts of the world, but as yet this work

has given only very inconclusive results. The methods of diagnosis and

especially the methods of selecting deviants for commitment to institu-

tions vary so widely from country to country and function so irregularly

in those parts of the world where European medicine is in contact with

preliterate peoples, that none of the statistical data is fit for comparative

study.

There is, however, some indirect evidence to show that, in fact, the

forms and frequencies of deviance do depend upon cultural circum-

stances. This evidence is derived from our communities. We find, for

example, that considerable changes in frequency of psychosomatic and

other psychopathological deviance occur from one period to another.

One of the most striking of these demonstrations concerns the sex-

distribution of perforated peptic ulcer. It has been shown repeatedly

(Alstead, 1939 Jennings, 1940; Mittelmann, et al y 1942) that, in the

latter half of the nineteenth century this condition affected more females

than males, in Western cultures. Mittelmann, ct aL, give the ratio for

New York as six males to seven females for the years 1880 to 1900.

The corresponding figures for the years 1932 to 1939 are twelve males to

one female. In the same paper, the authors examine the case histories of

a number of recent New York cases and show that perforated peptic

ulcer follows a definite type of psychological history and character

formation; that this background is at least as much a cause as it is an

effect of the ulceration ; and that the cultural changes in sex roles in the

last SO years have been such as would fit the striking change in sex

distribution.

It may be argued that the differences between New York of 1900

and New York of 1935 are, at most, only of "subcultural" order. But

23] CULTURAL DETERMINANTS OF PERSONALITY 723

from this we would predict that, a fortiori, still greater differences in

form and frequency of psychosomatic deviance ought to occur between

basically different cultural milieux.

Another reply which might be made to those who criticize the typo-

logical and psychiatric approach for its handling of the problem of de-

viance would be based on the notion of configuration. The theories are

built upon a gestalt level of abstraction, rather than upon notions of

simple cause and effect. They presume that the human individual is end-

lessly simplifying and generalizing his own view of his own environ-

ment; that he constantly imposes upon this environment his own con-

structions and meanings ; and that it is these constructions and meanings

which are regarded as characteristic of one culture, as over against an-

other. This means that, when we approach a context of extreme deviance

when we look, for example, at the melting-pot communities of our own

culture we must be willing to see that heterogeneity itself may be a

positive standardizing factor.

Granted that, in such a community, individual experience is infinitely

various, and that each individual in New York City is, in this sense, a

unique product, we can still say that all individuals are alike in so far

as all have experienced the heterogeneity of the city; and, in terms of

this common experience, we may look forward to finding certain psycho-

logical resemblances among them. We can even find these resemblances

institutionalized in the cultures of such communities. Such poems as

John Latouche's Ballad for Americans, which rejoices in the richness of

a heterogeneous background, the quiz programs of the radio, and the in-

finite disconnected variousness of Ripley's Believe It or Not, are all

symptomatic of this standardization due to heterogeneity. Even in the

institutionalized curricula of higher education we can trace the analogous

tendencies towards the dissection of knowledge into separate bits. We

find that high value is placed upon factual information and that the stu-

dent's progress is judged largely by the percentage of disconnected

factual questions which he is able to answer correctly. He is, in fact,

being fitted to live in a heterogeneous world in which generalizations are

hard to apply, and he is being taught a way of thinking suited to such a

world.

In fact, if we are willing to think at a rather high gestalt level, the

phenomena of deviance fall into place very simply, and support, rather

than conflict with, notions of cultural standardization. Extreme hetero-

geneity becomes a factor of standardization, and the isolated accident of

a single individual's upbringing equally falls into place. Human indi-

viduals do not live in a cultural vacuum, and the isolated accidental

deviant is faced with the problem of either accepting the norms of his

culture, or reacting against them. Moreover, to react against one norm

can usually only be done by accepting many of the premises upon which

the norm is based. The individual who resists a hierarchical structure

usually does so by attempting to rise in that structure; he accepts the

major premise that human life in his cultural milieu is structured in

724 PERSONALITY AND THE BEHAVIOR DISORDERS [23

hierarchical terms. So far as his character is concerned, it is molded to

fit the cultural emphases, even though he fight against those emphases.

In this sense, and at this level of abstraction, the attempt to describe

cultures in terms of the types of individuals which they foster is, I

believe, sound ; but a greater difficulty in the way of such an approach

is that the typologies upon which it is based are still very unclear.

The syndromes of introversion, extraversion, Apollonian and Dio-

nysian character, paranoia, etc., have not been critically and operationally

defined. This criticism, of course, is not one which the anthropologist can

be expected to answer. We have only taken the terms from other

disciplines and adopted them as a convenient tool, and it is not for us, in

this chapter, to examine the validity of these typologies. We may, how-

ever, express an opinion that the general notion of syndromes of person-

ality is sound even though the study of these syndromes is not yet

sufficiently advanced for us, in another science, to use them as tools.

Since various other methods of approach are available to us, we need not

delay our investigations because one descriptive technique is not com-

pletely satisfactory. Our solution is to supplement this technique with

others.

Description of Personality in Terms of the Socialization

Process

Since the description of syndromes of character is still in a somewhat

unsatisfactory condition, we have to proceed to use other descriptive

methods of relating character to the cultural milieu in which it occurs.

Of these, the most rewarding is the study of the socialization process by

which the child is educated to become a typical member of the com-

munity into which he was born. This method is, in a sense, historical,

rather than scientific. It assumes that a description of personality can be

arrived at in terms of the experiences through which the individual has

lived. The method accepts the fact that we have virtually no vocabulary

for describing what people are like, and substitutes for such description

statements about their past.

The great pioneer of this method was, of course, Sigmund Freud,

whose methods and hypotheses have been discussed elsewhere in this

volume. For the present chapter, it is sufficient only to note certain

peculiarities of the classical approach. First and foremost, Freud was a

therapist, and his contribution was a science and technique of therapy.

For this purpose, what we have noted as a conceptual failing in the

method, namely, the indirect description of the present through the invo-

cation of the past, was a positive advantage. The therapeutic procedure

was based upon communication between the therapist and the patient,

and for such communication an enormous new vocabulary of technical

terms descriptive of present personality would have been exceedingly

inconvenient. All that was necessary was that the patient should under-

stand himself ; it was not necessary that he should understand a general

CULTURAL DETERMINANTS OF PERSONALITY

725

science of personality structure ; and this understanding of himself could

best be conveyed in a language provided by the patient himself. The

incidents in the patient's anamnesic material provided such a rich variety

of illustrative and immediately relevant material that a more precise

terminology was unnecessary. In these circumstances, a whole massive

science of human behavior and character has been built up around less

than a hundred technical terms, and these, for the most part, are imper-

fectly defined. 5

When we try to examine Freud's contribution to our understanding

of culture, we very soon find that the preoccupation with therapy and the

resulting poverty of critical terminology makes it almost impossible to

arrive at any clear picture of Freud's opinions about the role of culture,

or his opinions as to whether human personality should be regarded as

fundamentally "the same" all over the world. That he believed that

similar processes (e.g., repression, displacement, introjection, projec-

tion, etc.) operated to produce human character in all communities is

clear, but it is not clear whether Freud believed that the products were

everywhere comparable or that the various processes have the same

relative importance in all cultures.

"Totem and Taboo" (Freud, 1904) is an attempt to dissect the prod-

ucts of these processes in Central Australia. Freud shows, for example,

that the whole gamut of Central Australian ritual dealing with the ani-

mal, which is regarded as a clan ancestor or totem, can be seen as an

expression of ambivalent attitudes towards the father, and this analysis

satisfactorily covers both the general taboo on killing the totem and the

special ritual occasions on which the totem is killed, eaten, and mourned

for.

Freud, however, goes further than this and constructs a tentative

picture of the original patricidal act, by way of illustrating his hypothesis.

He suggests that the young men freed themselves from the tyranny of a

father, and even says: "Perhaps some advance in culture, like the use

of a new weapon, had given them the feeling of superiority." 6

This early attempt on the part of Freud to account for cultural phe-

nomena in terms of the psychological past raises, in dramatic form, the

problems of method and meaning upon which subsequent work has been

focused. Broadly, we may classify the various subsequent attempts to

use the incidents of the past as a descriptive vocabulary into three groups,

according to the sources for data upon past events.

5 The much younger science of stimulus-response psychology, dealing with a

very much simpler gamut of phenomena, has already between 100 and 200 technical

terms, many of them carefully defined.

e In a footnote to another part of the same paragraph, Freud gives an extract

from Atkinson's "Primal Law," in which, long before Freud, Atkinson says of the

young men : "A horde as yet weak in their impubescence they are, but they would,

when strength was gained with time, inevitably wrench by combined attacks renewed

again and again, both wife and life from the paternal tyrant." (Atkinson, J. J.,

1903, pp. 220-221) Freud does not comment on the parallel between pubescence

and the "new weapon."

726 PERSONALITY AND THE BEHAVIOR DISORDERS [23

For the practicing psychoanalyst, the principal source of information

about the past is the patient's anamnesic material, the picture which he

is now able to give us what he thinks happened at some past time. This

picture is, no doubt, a doubly distorted version of the real past events,

first distorted in terms of the interpretation which the patient put upon

the events when they occurred, and distorted again by the patient's mood

at the time when he relates them to the analyst. But in spite of this dis-

tortion, the anamnesic picture is undoubtedly a true source, in so far as

we use its contents solely as a means of describing the patient's character

and personality today in the consulting room.

Like the analyst, the field anthropologist uses an indirect source for

his information about the psychological past. It is not possible for him

to record the experience and behavior of the same individual year in and

year out, from birth through adolescence to adult life, which, though

cumbersome, would perhaps be the ideal genetic approach. Instead of

doing this, he argues that the adult natives whom he can observe today

presumably had childhood experiences similar to those of the children

of today. He therefore endeavors to describe the adults whom he sees

in terms of the way the children of today are treated and the way the

children behave under that treatment. (For an examination of this

method, see Lass well, 1937.)

To those who are familiar only with rapidly changing communities,

where the cultural norms vary from year to year and a craze for putting

babies on schedules may rise and fall in a decade, the basic presumption

that a native culture may be stable for over thirty years may seem in-

credible. In general, however, it is justified. Before contact with the

white man, the cultures of preliterate peoples were changing much more

slowly than European cultures and their norms were much more clearly

defined than ours; and further, it is not difficult for the ethnologist in

the field to form an estimate of the degree of disruption which the culture

has suffered since contact began.

Using this method, we have come to a new evaluation of the role of

culture in shaping the personality and character of the individual. The

original Freudian position, which gives maximal importance to the family

constellation, still stands unchallenged ; and there is no doubt that it will

continue to stand. We have, however, come to realize that the family

constellations the behavior patterns between the members of the family

and the attitudes which underlie these patterns differ very profoundly

from culture to culture. At the physiological level, we can, of course,

refer to the processes of sex and reproduction as universal, but when

we come to use these terms as counters in psychological discussion, we

find that they may mean very different things in different cultural sys-

tems. Sexual initiative may come typically either from the male or

from the female (as among the latmul of New Guinea), and the sexual

act may be conceived of as aggressive (as among the Mundugumor) ; or

as affectionate (as among the Arapesh). The relationship between man

and wife may be predominantly tinged with dominance-submission, or

23] CULTURAL DETERMINANTS OF PERSONALITY 727

with succoring-dependence, or with exhibitionism-spectatorship, or with

any of the many variants of competition or cooperation ; and these char-

acteristics may be relatively standardized in the most varied ways in

different communities.

This means that the constellation into which the child is born, the

Oedipus situation which he encounters, varies profoundly from culture

to culture. When the child is added to a previously existing relationship

involving the two parents, the behavior of the latter towards the child

will inevitably be a function of their relationship to each other. 7 Their

relationship to each other was in large measure shaped in terms of the

conventions of their culture, and where it deviated from those norms the

parents were, consciously or unconsciously, influenced by the fact of devi-

ation. Similarly, their behavior towards the child is in large measure

conventionalized, and both they and the child, when they deviate from

the conventions, deviate not in a vacuum but with conscious or uncon-

scious recognition of deviation.

Thus, in healthy cultures, we find that a very high degree of uni-

formity of character is passed on from generation to generation, and in

unhealthy cultures we find sometimes no less uniformity. Among the

Mundugumor (Mead, 1935) we find that deviance and the guilt of

deviance are passed on, rather than simple conformity. The marriage

system of these people is so complex and so demanding that, as a matter

of fact, no marriages at the present time follow the native convention.

In spite of this, all are alike in suffering from their deviation from the

cultural standard.

So far, we have considered only what might be called the "content"

of character and personality, and we have noted that very profound

differences occur in what patterns of behavior are passed on to the child.

If we go on from this to ask how these patterns are passed on, we find

that here again differences occur from culture to culture. It is common

in Western cultures to find that the growing child builds up a set of intra-

psychic habits of self-approval and self-disapproval. This super-ego is

modeled upon the child's impressions of the character of one or the other

parent. This valuational system may or may not be consistent with other

intra-psychic systems in the same individual, and where discrepancies

occur we observe the phenomena of guilt. The super-ego system may

even be differentiated to such a point that it can be hallucinated as a

scolding voice or the like.

This whole system clearly depends upon a very specific set of cir-

cumstances. For the establishment of an organized and more or less

personified super-ego, such as we are familiar with in Western cultures :

(a) the inculcation of cultural norms must be predominantly reinforced

by punishment (including threats of withheld affection under this term) ;

7 I understand that Dr. Kurt Lewin has recently initiated studies of such triangu-

lar relationships, first observing the patterns of behavior between two children and

then adding a third child and observing the readjustments which follow this addition

(Unpublished).

728 PERSONALITY AND THE BEHAVIOR DISORDERS [23

(b) the punishing role must be played by some individual adult (a parent

or parent substitute) ; and (c) the behavior of this punishing parent

must be such that some species of close affective tie is established between

the child and the parent. These three conditions may be varied in many

ways, according to local convention. The punishment may be intense or

mild, regular or irregular ; it may be done in anger or in cold blood ; the

introjected parent may be male or female (as in Manus) ; the affective

tie may be strong or weak ; it may have various characteristics and may

be broken in various ways. But, provided these three conditions are

somehow fulfilled, we may expect to find some structure in the native

personality which we can recognize as a "super-ego/'

These three basic conditions for this type of character structure are,

however, by no means universal. Indeed, it is probably rather rare to

find them all in combination. In a very large number of cultures (Samoa,

Lepcha, Bali) the baby spends the greater part of its time in the care of

some little girl, so that if any strong affective tie is developed (and in

such cases the baby is often treated more as a bundle than as a person),

the introjected personality will be, not that of an adult, but rather that

of a juvenile.

In other cases, punishment is very rare (Samoa) ; or it may be car-

ried out by some person other than the parents. Among many American

Indian tribes, punishment is done by masked dancers. Unknown to the

child, the parents call in these punishing agencies. When these dancers

arrive, the parents go through an appearance of pleading with them, ask-

ing them to spare the child. Or, again, the inculcation of cultural norms

may be done by invocation of "what other people will say," establishing

a proneness to shame rather than to guilt, and introjecting a vague multi-

tude rather than a single personality. (For a general discussion of these

variants, see Mead, 1940b.)

Of special interest are the variants of character structure which de-

pend upon the type of affective tie established between the parent and

the child. In English-speaking cultures, this tie, in childhood, contains

many complementary components. These are patterns of behavior in

which the roles of parent and child are differentiated one from the other

and mutually complementary (e.g., dominance-submission, succoring-

dependence, exhibitionism-spectatorship, etc.). But the business of grow-

ing up consists largely in substituting more symmetrical patterns of

behavior. In both England and America, we find strong insistence that

the child, as he grows up, shall not react with overt dominance or sub-

mission in relationships with people stronger or weaker respectively than

himself. But, while in England the remodeling of these ties is often done

by drastic separation between parents and child, such as sending the child

to boarding school, in America the same function is usually performed by

the parents themselves, who respond with admiring spectatorship to any

signs of independence and self-sufficiency which the child may exhibit.

Thus, in both cultures, we develop a character structure in which sym-

metrical patterns are superposed on a complementary base, These cul-

23] CULTURAL DETERMINANTS OF PERSONALITY 729

tures differ, however, in the relationship between these two layers (see

Bateson, 1942a).

In some of the other cultures of the world, there is no reversal of this

sort, and we know of still other possibilities :

(a) The behavior of the parents may be such that from the very

beginning, symmetrical patterns are emphasized. Among the latmul of

New Guinea, the mother behaves as if the child were as strong as she

(Mead, 1940a). She first resists the child's demands for food, and later

gives way to them in response to the child's temper, "the child was too

strong." Any sort of punishment is preceded by a chase, and usually the

child is "too quick" to be caught.

(b) The behavior of the parents may be such that any tendency which

the child may have towards developing close affective ties is discouraged

from the very beginning. The Balinese mother (and the child nurse)

very much enjoys the responsiveness of her child, and often prompts the

child to respond, either by small teasings or by affectionate advances.

She was, herself, once a Balinese child and had a Balinese mother, and so

she herself is not responsive in the same way as the young child. The

child responds to her advances either with affection or temper, but the

response falls into a vacuum. In Western cultures, such sequences lead

to small climaxes of love or anger, but not so in Bali. At the moment

when the child throws its arms around the mother's neck or bursts into

tears, the mother's attention wanders (Bateson, 1941).

Thus, by using the details of childhood experience as a vocabulary

for describing character structure, and studying the parent-child rela-

tionship in various cultures, it is possible to show that the cultural milieu

is relevant to character and personality at many different levels. It may

contribute to determining the content; the list of behaviors which are

passed on from generation to generation is different for every culture.

More fundamental than this determination of content, the cultural milieu

may, by altering the contexts of learning, contribute to shaping the inter-

pretation which the child habitually places upon his own acts and upon

the universe in which he lives. The child who has learned by punish-

ment will see one sort of world, and the child who has learned by reward

will see a different world. Finally, at a still more fundamental level, the

cultural milieu may determine the manner of organization of the learned

behaviors. In some cultures, these are elaborately organized into an

image of a parent, but it is clear that other types of intra-psychic organ-

ization may occur.

The Study of Interpersonal and Intergroup Attitudes

The strong tendency in science to look for cause has led us to try to

describe adult character in terms of childhood experience; and, indeed,

this approach has so far proved rewarding. But this is not the only scien-

tific method, and several attempts have been made to use adult behavior

730 PERSONALITY AND THE BEHAVIOR DISORDERS [23

itself as a descriptive medium. One can build a systematic classification

of behaviors rather than a systematic accounting for behaviors.

This method is necessarily very cumbersome and exacting, and prog-

ress in it will depend more and more upon the use of strict operational

definitions and the techniques of mathematics and symbolic logic. When

we put adult behavior beside childhood experience, it is not necessary to

be very precise in our description of either set of observations, since some

extra clarity is given by the juxtaposition. But when we have only a

single set of phenomena and must somehow deal with them in their own

terms, a very much greater stringency is necessary, not only in our re-

cording of the phenomena, but also in the formulation of the problems

which we hope to solve and the analytic procedures which we apply to

our collected data.

We have noted, above all, that all the details of behavior and circum-

stance which go to make up what we call a culture are interrelated, and

very little thought is sufficient to show that various sorts of interrelation-

ship occur in every culture. We have, for example, all the relationships

which must be considered if we want to understand the integration of

the community at a strictly sociological level, and if this is the sort of

problem which we set out to solve, we have to put side by side the details

of how the community is subdivided into groups and the factors which

make for union or dissension among these groups. This particular type

of functional approach will, however, scarcely help us towards a psycho-

logical picture of the individual in that society.

For such a psychological picture, there are various possible ways of

arranging our data, according to the sort of psychological insight which

we are seeking.

View of the World. The data can be arranged to give us informa-

tion about such matters as : native orientation in space and time, among

objects and among people ; native systems of cause and effect, the natives'

view of the universe in which they live, the sorts of logic and illogic

which they follow. This has not yet been done systematically for any

culture, though a real beginning has been made by the gestalt psychol-

ogists and especially the topological school, in experimental studies of

individuals of European and American background. At the preliterate

level, we have not been able to approach this degree of precision, but

from the crude survey work which has been done, it is evident that

marked differences among cultures can be revealed by this approach. We

find, for example, that in some cultures the whole ceremonial life is

geared to a calendar, so that the precipitating stimulus for any ceremonial

celebration is the date. In other cultures, again, we find that the date

is ignored, and ceremonial is precipitated by events at the human level,

such as birth and death, victories, harvests, quarrels, etc. Even among

calendric cultures we find variation. Our own calendar is a double sys-

tem, with the week as a simple cyclic motif, while the days and months

are built into an endless on-going system. For us, the cyclical motif is

23] CULTURAL DETERMINANTS OF PERSONALITY 731

comparatively unimportant ; we forget the day of the week on which we

were born but remember the day of the month, and the serial number

attached to the year. In Bali, on the other hand (Bateson and Mead,

1942), the cyclical motif is all-important, and any individual can tell you

that he was born "on the third day of the five-day week and the sixth

day of the seven-day week," and he will probably be able to tell in which

month he was born in the twelve-month sequence. He will not be able

to tell in what year he was born and is not interested in this question. 8

Differences of this order are more than mere details of the calendar,

and if we examine the rest of the culture, we find that the same type of

difference in the perceived pattern goes through the whole of life. Our

world is shaped in terms of the notion that the past was different from

the present and that the future will be different again. The Balinese

world is based on a presumption that the present is only a repetition of

the past and the future will continue in the same circular fashion. The

two cultures are, however, alike in using spatial metaphors in referring

to temporal sequences.

Goal Orientation. A second method of arranging the data will give

us, instead of a cognitive 9 picture, a picture of goal orientation. We

noted above that the Balinese child is continually frustrated in the

climaxes which should follow his sequences of love and hate behavior,

and when we examine the adult behavior we find that there are no

sequences of mounting tension in interpersonal relations, no factions,

and no oratory. Equally, there is no mounting tension in efforts to deal

with impersonal barriers. The Balinese have no word for "to try hard/'

and their goal orientation is not strengthened by any appreciation of the

sequence of contrasts in which mounting tension is followed by release.

They do not purposely increase their intra-psychic tensions in order to

increase the ultimate satisfaction of release, as we do with apcritijs or

by deliberate abstemiousness.

Affective and Postural Patterns. The data may also be arranged

to give an "affective" picture of the system of linked responses. At a

very simple postural level, we may observe that, in our own culture,

people tend to leave their fingers, when at rest, in regular positions. If

the fingers are flexed, they will either be all flexed to the same extent,

or, if differentially flexed, the differences will follow some regular system

of progression, commonly each flexed a little more than its neighbor on

the radial side. The Balinese, very much more often, leave their fingers

in what appear to us to be distorted positions, as though each finger were

8 There is, in Bali, a system which gives serial numbers to the years, but this is

not used except by the most pedantic. The majority of the Balinese scholars are

content to date their everlasting manuscripts with the day of the week and the name

of the month.

9 The old terms, cognitive, affective, and conative, are here used to refer not to

artificially isolated processes which are supposed to occur in organisms, but to

different sorts of generalization which we arrive at by different methods of arrang-

ing our data.

732 PERSONALITY AND THE BEHAVIOR DISORDERS {23

a separate entity or a separate sense organ. True, in our culture, it is

polite in certain sections to extend the little finger when holding a tea-

cup, but in Bali this sort of thing is enormously developed, and photo-

graphic records show that the tendency to disharmonic finger postures

increases in the extreme excitement of rioting over the body at funerals

(Bateson and Mead, 1942).

Building further on this picture, we find that in witchcraft the em-

phasis on discrepancy between body parts reaches its height. We find

play with fantasies of one-footed balance, and evil spirits consisting of

single body parts, personified legs, arms, heads, and even spirits which

have a face at every joint.

With this sort of synthesis we arrive at a culturally limited descrip-

tion of "fear," putting together a study of postures and contexts in which

certain postures are exhibited. And there is no doubt that comparative

studies of different cultures on these lines will show very profound dif-

ferences in the organization of emotion.

Interpersonal Behavior. Lastly, we can arrange our data to give a

picture of interpersonal behavior sequences. Here, again, our main diffi-

culty is with the operational definition of our concepts and units, and

progress will be delayed until we have clear operational definitions of

dominance, submission, dependence, exhibitionism, narcissism, climax,

identification, and the like. One very significant attempt, however, has

been made by Chappie (1939, 1940). Using a small machine with a

recording drum, Chappie obtains a record of the duration of all overt

behaviors in a conversation between two or more individuals. He ignores

completely the verbal content and "meaning" of the behavior, and con-

centrates attention entirely on the time properties. This simplification

gives him the chance to define "initiative" operationally in terms of time

relationships, and his data are such that he can proceed to a statistical

study of "initiating behavior," "interruptions," "duration of responses,"

etc. The results show very marked differences between individuals and

especially marked peculiarities in the case of deviant and psychopathic

personalities.

We may expect that application of these methods to individuals from

cultures other than our own will show marked differences, and that this

method will give us useful abstractions for the handling of cultural

characteristics.

Conclusion

We may sum up our knowledge of cultural determinants of per-

sonality by saying that, while culture is not by any means the only

determinant, it is very important. The whole of human behavior as we

know it (with the possible exception of some reflexes) is either learned

or modified by learning, and learning is, in large measure, an inter-

personal process. The contexts in which it occurs vary from culture to

23] CULTURAL DETERMINANTS OF PERSONALITY 733

culture, as also do the methods of reinforcement. Thus, not only what is

learned is, in some measure, culturally determined, but also the role of

the learned behavior in the psychic life of the individual. Eating may

mean nearly the same thing to a starving man in whatever culture, but in

the ordinary course of everyday life, apart from the extremes of depriva-

tion, we must expect every one of the simple physiological behaviors,

such as eating, defecation, copulation, and even sleep, to have special

meaning for the individual, and this meaning will be culturally deter-

mined and will vary from culture to culture. Our task, as anthropologists

or psychologists, is to recognize and define the regularities in this com-

plex tangle of phenomena.

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Chapter 24

ECOLOGICAL FACTORS IN HUMAN BEHAVIOR

By ROBERT E. L. PARIS, Ph.D.

THE ECOLOGICAL ORDER, which emerges from a process of competition,

may be distinguished from the cultural order which is based on different

processes, even though these orders are never in actual occurrence com-

pletely independent. The coherence of the ecological order is based on

relations of a symbiotic character, similar to the symbiosis that produces

the elaborate and interdependent communities of animals and plants, in

that it arises automatically and unintentionally out of the struggle for

survival. The component elements cooperate without knowing it, or at

least without having to know it (Park, 1939).

Durkheim (1893) has called this an "organic solidarity" because it is

based on an organization of complementary differences, in which the in-

dividuals are utilities to one another, rather than objects of sentiment

and affection. The bonds that hold together the populations of an indus-

trial city are of this type.

The cultural order, based on consensus relations, is found only among

human beings, as it requires psychological characteristics not possessed

by simpler organisms. It is, in Durkheim's term, a "mechanical soli-

darity/' a cohesion of persons on the basis of their similarities, which

are valued on the basis of mutual affection and sentiment. The typical

family, friendship group, fraternity, is held together principally by this

relationship.

The simplest preliterate societies are maintained on a predominantly

consensus basis, but with the development of civilization, and particularly

industrialization, the symbiotic element has rearranged relationships and

penetrated more and more into social systems. This encroachment has

the effect of weakening and destroying much of the consensus unity in

society, and is therefore one of the important basic causes of the social

disorganization so conspicuous in industrial civilization, and, as shown

below, is an underlying condition for much of the abnormality in human

behavior of modern time. The most disorganizing ecological influences

are those which upset established consensus orders by causing large

movements of population. The consequences of such movements are so

great that they constitute some of the major social problems of modern

civilization.

736

24] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 737

Migration and Mobility and Their Effects on Culture and Be-

havior. The most important movements of masses of people are deter-

mined principally by ecological factors. This is the case with much of the

immigration to the United States, the flow of population from farms to

cities, and the flow of populations from the centers of the cities to the

suburban districts. There are, of course, certain types of migrations

such as religious pilgrimages, vacation migrations, refugee migrations,

and the like which are due to other factors, and there are also migra-

tions with mixed causes. The ecological migrations are the movements

in the struggle for a better place in the economic order. People desert

the less favorable regions when they find opportunities to better them-

selves in new places, and they move to more desirable places when they

find themselves able to support themselves there.

In recent times, due to the industrial revolution and to the settlement

of the Western Hemisphere there has been a rapid advance in the gen-

eral standard of living in the civilized countries (Ogburn and Nimkoff,

1940, Ch. 16). As a consequence there has been a great deal of eco-

logical movement upward in the occupational pyramid, and toward the

more favored regions on the earth's surface. Of the available studies

of the causes and nature of these movements there is little that is con-

clusive. The most satisfactory knowledge we have concerns the migra-

tion from rural to urban regions in the United States. There are some

grounds for holding that the general principles accounting for this migra-

tion apply to the others as well.

An issue that receives prominent discussion is the question of the

extent to which characteristics of persons initiate these migrations. Can

it be said that there are types of persons who are constitutionally inclined

to migrate, and will migrate regardless of economic conditions ? Or is it

that migrations follow from the general competitive forces, regardless of

the types of persons concerned ? The available research is not conclusive,

but the consensus of studies of rural-urban migrations favors the latter

alternative. The time of migration, for example, is very largely set by

the general condition, that is, by the occurrence of favorable employ-

ment opportunities in the areas to which the migrants move, and to a

lesser extent by particularly unfavorable conditions in the regions they

leave. This has been shown by several different methods in the researches

of students of population (Ogburn and Nimkoff, 1940, Ch. 15). These

studies indicate that migration varies in amount with industrial activity

in the regions to which the migrants travel, and in times of depression

not only stop but have a net reversal of movement. When prosperity

and depression cycles do not coincide in the regions left and entered,

the amount of movement relates more closely to prosperity in the region

entered, than to depression in the region left.

There has also been extensive examination of the matter of the selec-

tion of types of persons in these migrations. The literature has been

summarized by Gist and Halbert (1933) and by D. S. Thomas (1938),

and though the results are not as conclusive as might be wished, the data

738 PERSONALITY AND THE BEHAVIOR DISORDERS [24

appear to favor the conclusion that there is some selection in the migra-

tion, but that it is probably not a selection of a biologically different type.

The migrants are, as a rule, discovered to be slightly superior in general

ability and health to the nonmigrants, and to come from slightly superior

homes. If the findings of Smick and Yoder (1929) are typical, the

superiority is due mainly to the better opportunities, since the educa-

tional superiority did not manifest itself in the sample studied until some

time after the eighth school grade.

The conclusion most harmonious with the above data is that the high

rates of various types of defectiveness in populations which have under-

gone migration is not due to their previous inferiority, since the differ-

ences noted are more in the direction of superiority. It is more probable

that the migration, which resulted from ecological forces, caused the

behavior abnormality by disorganizing the social system.

Migration of the type under examination here has characteristic

effects on the behavior of persons ; effects which for the most part are in

the direction of abnormality. It achieves these by interfering with some

of the essential elements of cooperation. One of the essentials to normal

and conventional behavior is full membership in primary groups in com-

munities of stability. The migrant is separated from such membership

and therefore becomes increasingly individuated as the length of separa-

tion increases. This is borne out by studies of such mobile populations

as hoboes (Anderson, 1923 and 1940), rooming-house dwellers (Zor-

baugh, 1929; Cavan, 1928), and hotel-dwellers (Hayner, 1936). In

addition to this individuating effect, migration also has a secularizing

effect. The resident of a stable community who knows of no other ways

of life takes for granted the customs of his community, and regards as

outlandish and abnormal the deviations he hears of only occasionally

and distantly. But the migrant sees people living quite naturally in other

systems, apparently as contentedly as his own people in their culture.

When these alternative ways are seen to be successful his own ways

become less sacred and less inevitable, and begin to lose their hold on

him. Though it is possible that the ways of the outlanders could be so

previously defined that they would not break down the old loyalties, the

more usual effect of exposure to a different culture is such a seculariza-

tion of the attitudes.

The effect on a nonmigrant of residence in an area of high mobility is

similar. He has no stable community life, and is exposed to the secular-

izing influence of a variety of ways of living.

The ecology of behavior abnormality, then, is largely a matter of the

consequences of migration. The aspects significant to behavior are not

the migration itself, but the individuation and the secularization that are

the consequences of it. The material in the following sections has a con-

sistency which is intelligible in this light. High rates of behavior dis-

orders, with certain exceptions to be noted, are found in those areas

of social disorganization of the type which results from population

migrations.

24] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 739

Behavior Disorders and Regional Variations

Comparison of Preliterate and Civilized Societies. A major bar-

rier to reliable comparisons between preliterate societies, and between

preliterate and civilized societies, is the scarcity of accurate knowledge

of the incidence of the various forms of behavior abnormalities in pre-

literate societies. Certainly it cannot be said that abnormalities do not

exist in the simple cultures, as a number of reliable reports establish

their existence (Gillen, 1939). But there do exist societies in which

crime is so rare that it may be said to be virtually absent. And there are

reports of a number of societies in which suicide is unknown (Cavan,

1938, Ch. 4). There is also evidence that in some societies functional

mental disorders are rare or absent (Faris, 1934). It may be that varia-

tions in culture account for variations in behavior abnormalities in pre-

literate as well as civilized societies. The difficulty of establishing stand-

ards in such a relative matter as abnormality, and the difficulty of

getting accurate information, may frustrate the research on this point for

some time to come. It may be that the Cross-Cultural Survey which is

being built up at Yale University will provide material adequate to a

satisfactory analysis of this question.

Racial and National Variations. Material on racial and national

variations is only a little more satisfactory than on preliterate societies.

International comparison of crime rates is difficult because of the varia-

tions in laws and enforcement mechanisms. Comparison of rates of

mental abnormality are prevented by lack of standards of diagnosis,

hospitalization, and other factors. Suicide rates would appear to be more

comparable, but there are the questions of completeness of reporting,

definitions of suicide, and intentional distortion of the records. In spite

of these difficulties, the general study of suicide by Halbwachs (1930)

is very consistent and convincing. The comparisons point to the relation-

ship between high suicide rates and the degree of industrialization.

Material in the studies of Cavan (1928) and others (Frenay, 1926;

Dublin, 1933) which relates high suicide rate to urbanization, and to

the highly mobile populations of the cities, strengthens this conclu-

sion.

Many comparisons of racial and nationality groups within the United

States, with respect to behavior abnormalities, have been made. Where

conclusions have been drawn they have been subject to the criticism that

the conditions under which these groups live vary so greatly that the

statistics may reflect these conditions rather than racial characteristics

(Klineberg, 1935). In view of the large variations within racial groups

which have been demonstrated (Frazier, 1939), and in view of the

narrowing or disappearance of some of the racial differences when con-

ditions approach equality (Klineberg, 1935), it appears likely that

most of the variations in abnormality between racial groups is due to

differing conditions of life, and very little if any to differences in racial

740 PERSONALITY AND THE BEHAVIOR DISORDERS [24

biology. Where the statistics are intelligible at all, they are in harmony

with the explanation in terms of social disorganization presented above.

Regional and State Variations within the United States. The

ecological sorting of populations and activities is not so much distribu-

tion by states and regions, but rather a nucleated arrangement in smaller

areas. Many states, for example, contain large cities as well as farms,

foreign-born as well as native-born populations, migrant and stable

populations, and so these extremes cancel out to some extent. Thus the

contrasts in rates of crime and mental disorder in the major regions of

the country are very small in comparison to the contrasts in the different

sections of the large cities. In so far as there seems to be any meaning

in such regional comparisons, it also is apparent that differences in

behavior abnormality are associated with the disorganization of indus-

trial areas. Certain forms of abnormality, however, are not particularly

characteristic of industrial regions. Although most forms of professional

crimes against property have their highest rates in the industrialized

regions of the northern states, some crimes are not so concentrated in

their distributions, and others, such as murder, which has its highest

rates in the southeastern states, offer a sharp contrast.

Rural-Urban Variations. In some respects the rural-urban com-

parisons are more satisfactory for showing contrasts than are regional

comparisons, but this method also fails to bring out the most significant

differences. Cities are neither adequately nor uniformly defined by their

political boundaries, nor are cities uniform in their composition. The

industrial cities which have been expanding rapidly have a considerable

amount of social disorganization, but it is only a part of the city which

is affected. The rates for entire cities fail to bring out the contrasts with

rural areas because the extremes within the cities are averaged together.

Nevertheless, cities have in general higher rates of abnormal behavior.

The rates for the professional types of crime burglary, robbery, lar-

ceny are higher in the cities than in rural areas (Ogburn and Nimkoff,

1940, p. 534). Suicide has higher rates in urban areas (Cavan, 1928,

p. 77; Sorokin and Zimmerman. 1929, p. 173). Mental disorders, all

taken together, show higher rates in urban areas but some types of

mental disorders show the reverse, and other types show little relation-

ship to urban or rural areas (Sorokin and Zimmerman, 1929, pp. 264-

265). The suggestion is made that the incidence of mental disorders

might not actually be different in rural and urban areas, but that the

apparent difference could be due to the difference in likelihood of

noticing and committing persons who are psychotic (Landis and Page,

1938, pp. 53-55; Owen, 1941). Among the 1917 United States Army

draftees, however, more urban than rural men were rejected because of

mental disorders (Love and Davenport, 1920, pp. 351-352). The har-

mony of the rural-urban comparisons with the more carefully demon-

strated comparisons between areas of the city also confirms that there

24] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 741

is a real difference in incidence. This is related to differences in degrees

and types of social disorganization (Paris and Dunham, 1939).

Behavior Disorders in Urban Areas

The Urban Ecological Pattern and Its Relation to Mentality,

Behavior, and Social Institutions. By far the most extensive, method-

ical, and fruitful ecological studies dealing with behavior are those based

on comparisons between sections of large industrial cities. Following the

analysis of "natural areas" of the city by Burgess (Park and Burgess,

1925), a considerable body of knowledge of urban ecology has been

accumulated. It is necessary only to summarize the essentials here. The

industrial city grows mainly by adding population through migration

of unskilled persons who come from smaller cities and rural areas, and

from other countries. These enter the industrial system at the bottom,

and reside in the central industrial slum regions. As they become estab-

lished these populations move upward in the occupational pyramid, and

outward in the city toward more desirable residential areas, and their

places in the slums are taken by newer arrivals. The principal char-

acteristics of the urban areas, however, remain virtually constant as

these streams of population pass through. Some of the behavior char-

acteristics of the people are formed by their experiences in these areas,

and change when they leave the areas. These characteristics include

many aspects of community life, social institutions, political behavior,

and other normal and abnormal behavior. Because these conditions

remain with the area rather than with the racial or national group, it

can be said that they are ecologically determined. By this it is not meant

to imply that human nature is of no significance in the behavior, but that

innate variations in human nature do not account for these area varia-

tions in such behavior traits as crime, vice, suicide, and other forms of

abnormal behavior.

Delinquent and Criminal Behavior. The most important work on

the urban ecology of crime is that done by Shaw and his associates ( Shaw

and McKay, 1931). The foundation of the study was made in Chicago,

and the results were checked against less complete studies in more than

twenty other cities. The relationship of the type of delinquency that

leads to the career type of crime is very clearly shown to grow out of

the disorganization that has its roots in urban ecology.

A fact noted in the studies of all the cities is that the incidence of

juvenile delinquency varies markedly according to the section of the city.

The slum sections, usually but not always near the central parts of the

city, inhabited by low-paid working people, with a high proportion of

foreign and Negro populations, have relatively very high rates. The

outlying residential sections, inhabited by native-born, business and pro-

fessional population, have very low rates. In the intervening areas there

742 PERSONALITY AND THE BEHAVIOR DISORDERS 124

Figure 1

Rates of juvenile delinquents in districts of Chicago, based on 9,243 alleged

male juvenile delinquents in the 1921 police court records. (From the Report on

the Causes of Crime, National Commission on Law Observance and Enforcement,

Vol. II, p. 30)

24] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 743

is a gradation of rates according to the proximity to the slum areas

(see Figure 1). Although the point has been made (Robison, 1936)

that rates based on court cases may not necessarily be an accurate index

to the amount of delinquency, enough evidence of other kinds converges

to establish the point that the rates really do vary in the above manner

(Shaw & McKay, 1931).

Taking selected areas in Chicago for special examination Shaw and

McKay (1931, pp. 86-98) showed that the rates for the German, Irish,

Scandinavian, Italian, Slavic, Negro, and other groups are all high when

these groups inhabit the disorganized areas, and that they decrease as

these groups move out toward the more stable residential districts. The

rates for each racial or national group within the same areas were not

identical, but the variation between these groups is much less than the

variation between areas.

In a highly methodical and satisfactory fashion the Shaw and McKay

study worked out a sociological explanation of the persistence of the

high delinquency rates in these disorganized areas. Hypotheses to ac-

count for this on the basis of the innate characteristics of the delinquent

are too much in conflict with the facts to be acceptable. The explanation

of delinquency as due to low mentality, for example, breaks down under

the careful and critical examinations of Sutherland (1931) and Tulchin

( 1939) . The delinquent population does not appear to be in fact men-

tally inferior to the nondeliquent population living in similar conditions,

nor does there appear to be any innate inferiority to the law-abiding

population in general. Explanations of delinquency based on mental dis-

order, neuroses, mental conflict, also fail to stand critical examination.

That is not to deny that there are delinquents with these forms of mental

abnormality, but that such abnormality accounts for any large part of

the delinquent behavior in the population. A study by Dunham (1939)

of the catatonic schizophrenic cases and the delinquency cases in an area

having high rates of both, showed that virtually none of the delinquent

boys were in the catatonic group, and none of the catatonics had a

record of delinquency. This finding is in harmony with the characteriza-

tions by Thrasher (1927), and Shaw and McKay (1931, pp. 222-

257) of the members of delinquent boy gangs as normal, sociable, and

lively.

There is reported a type of delinquency which is related to mental

difficulties conflict or light neuroses and the like and which is not

necessarily learned from other boys but is devised by individuals. It is

expressed in such behavior as petty and useless stealing, and patho-

logical lying. This type of delinquency is different in several respects from

the normal gang behavior of the slums. It is not particularly character-

istic of low-income classes or disorganized areas. It is not related, as is

the gang behavior, to adult professional crime. It is not, so far as is

known, related to urban ecology, and is therefore not further examined

here, but left to the social psychologist or psychiatrist to explain.

The delinquent gang behavior, on which most adult professional

744 PERSONALITY AND THE BEHAVIOR DISORDERS [24

criminal careers are based, grows out of the special social situation

characteristic of areas which are disorganized by ecological processes.

The most important factor in accounting for the delinquency is the

breakdown of the social conditions which maintain normal and conven-

tional behavior in the stable community. It is the integration of fam-

ilies with neighborhood communities that makes possible the type of

informal social control that operates in small towns to maintain obedi-

ence to the customs and mores. In such a situation each person is

known to all the others in his neighborhood and has a reputation to

maintain. The supervision of behavior by neighbors and acquaintances is

extensive, and the sharing of observations through gossip increases the

range of information, so that the person is under virtually constant in-

spection of others in such a community, and his status is regulated by

their judgments. In the normal conditions of community life, this type

of control is sufficient to maintain normal and conventional behavior

without the aid of such formal agencies as police and courts, and without

supernatural sanctions for the control of behavior.

Although the mechanisms of formal enforcement of the laws are far

more developed in the large cities than in the small towns, the delinquent

behavior is not successfully controlled by them. The ordinarily effective

informal control of the family and neighborhood is unable to operate in

the disorganized parts of the city. Two important conditions producing

the disorganization are the mobility and the heterogeneity of the popula-

tions in these areas. Not only is a large proportion new to the city and

even to the country itself, but the movements of persons within the area

are much more frequent than in the typical small town. This means that

most persons live among strangers, who are relatively indifferent to their

behavior, and who do not preserve a collective memory of each person

and a reputation to guard. The small-town father may appeal with some

force to his children by saying, "What will the neighbors think of us

when you do that? You might disgrace the whole family/' In the

mobile parts of the city there are no neighbors in this sense, and so there

is much less possibility of disgrace. The heterogeneity of races and

nationalities, with their transplanted culture traits from their former

countries, produces a variety of standards of behavior which allows for

more choice and freedom than does a single moral standard. The experi-

ence of living in a community with an assortment of nationalities makes

interfamily cooperation in supervising children's behavior much more

difficult. Where race prejudice complicates the pattern, hostility toward

neighbors further decreases the possibility of informal social control,

except in such communities as Chinatown and the Orthodox Jewish

Ghetto, where the hostility may be of such strength as to increase the

solidarity and the social control within the group.

The result of such neighborhood disorganization is that families have

difficulty controlling their children. In some cases the delinquents come

from families in which delinquencies are allowed or even encouraged,

but this is not the case with the major part of them. Most families try

24] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 745

to control the behavior, but fail, due to the circumstances mentioned

above. Some homes of delinquent children are incomplete, due to death,

divorce, or separation of parents, but this is not in itself a major factor

in delinquency. It has been shown that both the broken homes rates

and delinquency rates vary according to age groups and according to

the section of the city. When the influence of age and area is removed,

the difference in broken homes rate between delinquent and non-

delinquent children is little or nothing (Shaw and McKay, 1931, pp. 261-

284). The more significant factor, then, is neighborhood disorganization

rather than family disorganization by itself.

Mere lack of control by family and neighborhood does not in itself

determine that children shall become delinquent. There are positive

factors at work to maintain the delinquent patterns of behavior in these

areas. A tradition of delinquent behavior is maintained by the children

and transmitted from generation to generation in the same way legiti-

mate traditions are transmitted. Each boy learns his first delinquency

from experienced boys, and in turn transmits the techniques to younger

ones. In practically all the cases of this type of urban delinquency, boys

are taught their first delinquency in such an apprentice relation. As

each boy graduates to more advanced techniques he is taught these also,

by those ahead of him in the system. The arrangement is informal, but

regular in pattern. The types of delinquency have a sequence, begin-

ning with such simple types as stealing fruit and vegetables from an out-

door stand, stealing milk bottles from back steps, and the like, through

such more advanced practices as shoplifting, burglary, auto thefts, and

robbery with a gun. Not only the first of each type, but the large

majority of all these delinquencies is committed in groups (Shaw and

McKay, 1931, pp. 191-199). ~

In so far as motives can be inferred from observation of this behavior,

it appears that hunger or need is not important in the beginning of the

process. Even though food is often stolen, it is frequently not eaten, but

taken for the excitement involved. A favorite game is to let the pro-

prietor of a fruit stand see the theft of fruit, then as he pursues, to throw

some of the fruit on the ground, watching with amusement his conflict

between the desire to salvage his property and to catch the thieves.

This has the meaning more of a good sociable athletic contest, than

of a grim effort to stay hunger. Such a motive as revolt from authority

is no more in harmony with the observations. While it is true that older

criminals sometimes plan, during incarceration, to take "revenge on

society/* the boy delinquents appear to be merely following a social code

with little thought of its meaning to the nondelinquent community. They

realize that their delinquency is disapproved, but consider the law-

abiding population somewhat as the opposing side in an athletic con-

test.

The whole system of prestige in the criminal organization is based on

the difficulty and danger of the crimes, so that a boy finds the means of

gaining status by learning the more advanced techniques. The older,

746 PERSONALITY AND THE BEHAVIOR DISORDERS [24

more experienced men the "big shots" are respected and looked up

to by the younger boys, who have the ambition to reach the advanced

stages themselves in time (Shaw, 1930). When fear causes a faltering

spirit in the commission of a dangerous crime, the possibility of disgrace

with the members of the gang may prevent withdrawing. In the Shaw

study of Sidney Blotzman, who was arrested for committing rape, it is

evident that the crime was not due to a sexual craving, but to the desire

not to lose caste in the eyes of the gang (Shaw, 1931). In general, the

research on the nature of the delinquent gang boy points to the con-

clusion that he is not innately different from the normal population but

that his activity is governed by a separate tradition. His motives for

participating in that tradition are similar to the motives of normal per-

sons in a conventional tradition.

The delinquent tradition is also favored by certain other conditions

in the cities, such as the corrupt and rewarding alliance between busi-

ness, politics, and crime, and the existence of "fences" for receiving

stolen property, which help to make a career in professional crime

profitable.

Organized Vice. The principal ecological study of vice is that by

Reckless (1934). The interpretation is, in general, similar to that of

delinquency. Organized vice is made possible by the disorganization of

the communities. It is maintained by a business-like organization of

persons who do not differ markedly, on the average, from the general

population in innate capacities. There are three distinct groups in-

volved: the entrepreneurs, the prostitutes, and the patrons. The en-

trepreneurs are, for the most part, members of the professional criminal

organization described and explained above. The prostitutes have a

history similar to that of delinquent boys. A high proportion of them

began their sex delinquency as young girls, in the same manner as boys

begin their delinquencies (Crook, 1934). The behavior is learned, and

motivated more by social motives than by individual sex craving or

desperate need to gain a living (Thomas, 1923). After a period of

free sex delinquency the career possibilities are recognized, much as

the career possibilities of crime emerge after apprenticeship in delin-

quency.

The patrons are not all members of the criminal group, but come

from a wider population, including some from the upper income groups

and stable residential districts. But evidence based on examination of

the addresses of patrons caught in raids (Reckless, 1934) and on the

incidence of venereal diseases (Paris and Dunham, 1939, p. 1931) indi-

cates that the unmarried population of the rooming-hpuse districts fur-

nishes the largest part of this group. Zorbaugh's description of the

residents of this area (1929) and Cressey's study of the patrons of the

taxi-dance hall (1932) show the relation of the mobility of this popula-

tion to their disorganization, and to their failure to find adequate sex

experience in other than vice resorts.

24] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 747

Suicide. The most important ecological study of suicide is that

made by Cavan (1928), who established that the suicide rates in

Chicago vary in orderly fashion in the different parts of the city. A

study in Seattle by Schmid (1928) yields similar findings (see Figure

2). The high rate areas are the areas in which there is a high mobility

of population the central business district with a hotel and hobo popu-

lation, and the rooming-house and hobo areas near the central part of

the city. The apartment-house districts, though lower than the room-

ing-house in suicide incidence, have higher rates than the stable resi-

dential districts.

Suicide statistics cluster about three factors: a crisis or failure, a

sense of isolation or desertion, and a personality trait which might be

called the "quitter attitude." The first of these, the crisis factor, is

reflected in the increased incidence of suicides in times of economic

depressions, and in the increase during such catastrophes as pogroms

(Halbwachs, 1930). The second factor appears to be the one most

related to the urban distribution of suicide rates. The rooming-house

and hobo areas are inhabited by a highly mobile population. The resi-

dents of these districts are for the most part strangers to one another

and are socially isolated even though the area is densely settled. The

deterring effect on suicide of the knowledge that one will be missed by

family and friends, of obligations of various kinds to other persons, are

at a minimum here. This isolation factor is also reflected in other

statistics. Halbwachs (1930) presents figures on marital status and

suicide which indicate that marriage, especially if there are children, is

related to a lower suicide incidence. In France the figures indicate that

for each additional child up to the sixth, the expectation of suicide of

parents becomes less. After the sixth the rate levels off and remains

low. Halbwachs suggests also that the decline in rates during wars and

extreme political crises may be due to the general increase in social

solidarity at such times, and the consequent decrease in the sense of

separation from society (1930).

The personality factor in suicide is not primarily a matter for eco-

logical examination. Cavan presents material which suggests that the

definition of suicide as the way out of a crisis may be related to per-

sonality trends that begin in childhood, and may be seen in such indica-

tions as the wish never to have been born (Cavan, 1932). A proportion

of suicidal persons, perhaps a third, show signs of mental disorder, and

about an equal proportion are addicted to alcohol, which is an indica-

tion of a trait of evasion of difficulties (Halbwachs, 1930).

Mental Disorders. The most intensive ecological study of mental

disorders is the analysis of rates in Chicago (Paris and Dunham, 1939).

This study includes a check made in Providence, R. I., which though

less complete, agrees with the Chicago results as far as it goes. Subse-

quent to the publication of this study there have been studies carried

on in six mid-western cities. The preliminary results, reviewed by

74 8 PERSONALITY AND THE BEHAVIOR DISORDERS [24

SUICIDE RATES

MINNEAPOLIS: 1928-1932

LEGEND

RATE PfR 100.000 OF POPULATION

15 YEWS OF AGE AND OVER

DOTTED LINES INDICATE

PARKS. CfMlUPlES. AND

IhOUSTRlAL AND RAILROAD

WOPERMS.

Figure 2

Rates of suicide in districts of Minneapolis, 1928-1932. (From Calvin M.

Schmid, Social Saga of Two Cities. Minneapolis: Minneapolis Council of Social

Agencies, Bureau of Social Research, Monogr. Series No. 1.)

24] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 749

Queen (1940) are also in harmony with the more elaborate Chicago

study.

In Chicago it was found that the rates of first admissions, based on

the patients entering all the state hospitals and all the private hospitals

in the vicinity, varied in a highly regular fashion. The highest rates

are in the central business district; the next highest in the adjacent

areas, hobo and rooming-house; and the lowest rates are in the resi-

dential areas on the edges of the city. The regularity and extent of this

variation is shown by the rates for mile zones in radial segments of

the city (see Figure 3). For the segment extending south from the

central business district, the zone rates are, in order: 362, 337, 175, 115,

88, 74, and 71. For the segment extending to the northwest, the rates are :

362, 177, 95, 71, 66, and 55. Similar results are found for the three other

segments (Paris and Dunham, 1939, p. 36). When the rates are com-

puted by smaller areas, the range is much greater from 499 to 48.

These are average annual first admission rates for the combined years

1922-1934, inclusive, based on 100,000 population of 1930, age fifteen

years and over.

This concentration of rates does not in itself prove that the incidence

is actually higher in these areas of the city, or that the areas have any

direct causal relation to the rates. It is possible that such a result may

be explained in other ways. It may be that the incidence is the same

throughout the population, and that the higher rates in the central sec-

tions represent the higher tendency of low income classes to be hos-

pitalized. It may result from a statistical error due to the differential

transiency in the population. That is, if the cases from an area taken

during the period of a year are divided by the population taken as of a

single day, the rate may be regarded as too high if the population during

the year had turned over enough to make a significantly larger popula-

tion than was present on the one census enumeration day. Another

possibility is that the apparent concentration of rates is due to the drift

of persons to slum areas as a result of failures due to mental disorder,

that is, the concentration does not represent a causal relation of the area

to the psychosis but an inevitable drift to such residences by the

psychotics. It is also a possibility that the high concentration of races

merely measures the racial tendency to mental disorders of the foreign-

born and Negro populations that inhabit these areas. None of these

hypotheses account for the fact that the patterns of distribution of the

various psychoses are markedly different from each other, both in the

degree of concentration and in the regions in which the concentrations

occur. Further significant, if not conclusive, fragments of evidence

on these hypotheses are cited in the Chicago study (Faris and Dunham,

1939, pp. 160-167), making it possible to rule out some of them with

certainty, and supporting the conclusion that none of these suggestions is

likely to account for the pattern of rates. It seems highly probable that

the concentration of rates in the city represents a contribution of these

urban living conditions to the causes of mental disorder.

750 PERSONALITY AND THE BEHAVIOR DISORDERS [24

SUB- COMMUNITIES

CfiNSUSTRACTS

CHICAGO

AVERAGE INSANITY BATE

BASED ON 1930 POPULATION

AGE 15 AND OVER

LEGEND

1*0.0 AND OVER

OB 1200-149.9

HI 90.0-H9.9

BBS 600-899

EZJ 700-799

EZ3 UNDER 700

MAT PMCMRCO NT G.GCHMCIUA0

UNKft T* OMCCTION Of OH*

S AND CTNCL 9HANAS

OAT* fNOM TOW STATC HOSPITALS

AND CICMT WlVATt INSTlTUTlOMS.

Figure 3

Rates of mental disorders in districts of Chicago, 19224934. (From R. E. L.

Jans and H. W. Dunham, Mental Disorders in Urban Areas. Chicago: Chicago

University Press.)

24] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 751

The separate examination of the distribution of rates for each type of

psychosis reveals that they do not all show the same pattern. Schizo-

phrenia is highly concentrated, much in the same pattern as that of all

mental disorders together. General paralysis is concentrated principally

in the central hobo and rooming-house areas and in the Negro area.

Alcoholic psychosis is concentrated in these areas and in some of the

foreign-born slum areas. Manic-depressive psychosis is hardly con-

centrated at all, but very nearly shows a random pattern of rate dis-

tribution. Other distributions of rates for senile psychosis, arteri-

osclerosis, and drug addiction also reveal characteristic patterns.

The explanation of the pattern of general paralysis rates is not diffi-

cult to find. The rooming-house districts contain the bulk of the patrons

of vice resorts. Unpublished maps of the distribution of venereal dis-

eases in Chicago show that these diseases have the same distribution as

general paralysis. The relation of the rooming-house district to eco-

logical processes has been indicated above.

Alcoholic psychosis has high rates not only in the hobo and rooming-

house districts, but also in the foreign-born slum areas. Of all the

major types of mental disorder this is the most closely associated with

low income. Apart from the common-sense suggestion that addiction

to alcohol may be a response to hardships of life, there is not much basis

for an interpretation of this pattern. There is a suggestion of a cultural

influence, however, in the exceptionally high rates in the communities

inhabited by first and second generation Irish, and in the very low rates

in Jewish communities.

There is also little basis for interpretation of the pattern of arterio-

sclerosis and senile psychosis. The patterns resemble that for schizo-

phrenia. This may be coincidental, or may mean that there is some

overlapping of these cases with schizophrenia, either in confusion of

diagnosis or in the mixture of traits of schizophrenia in these forms of

mental disorder. There are other possibilities as well, but at present

insufficient data to make possible a reasonable choice between them.

Since the manic-depressive rates are distributed in a nearly random

pattern in the city it may be concluded that this psychosis has little

relation to any factors involved in urban ecology. This does not rule

out factors of experience which do not vary in the different urban areas,

but does leave the problem outside of the field of ecology.

The schizophrenia rates, as stated above, varied in about the same

pattern as that of all mental disorders combined. But separate examina-

tion of types of schizophrenia shows sharp differences in their distribu-

tion. The paranoid type is associated with hobo and rooming-house

areas, but the catatonic type has very low rates in these areas, and high

rates in the foreign-born slum areas. The hebephrenic rates are inter-

mediate, but somewhat closer to the pattern of the paranoid rates. These

contrasts are verified by correlation studies of the rates for each type of

schizophrenia with indices of conditions in the areas. The paranoid rates,

for example, correlate with the percentage of rooming-house and hotel

752 PERSONALITY AND THE BEHAVIOR DISORDERS [24

population of the city areas + .82, while the catatonic rates correlate

negatively with the same index with a coefficient of .29. The hebe-

phrenic rates are intermediate with a + .57 coefficient. On the other

hand, the catatonic rates show a high relation to the percentage of

foreign-born plus Negro percentages, -j- -86 ; for hebephrenic, + .40 ;

and for paranoid, + !! This does not mean that the catatonic cases are

necessarily more frequent in the foreign-born or Negro populations, but

merely more frequent in the same areas where those populations are also

frequent.

Owen (1941) attempts to account for the contrast in the schizo-

phrenic and manic-depressive distributions on the basis of a differential

probability of being discovered in different parts of the city. In regions

in which persons have a large number of primary social contacts it is

suggested that the behavior of manic-depressive and of schizophrenics

would not be equally conspicuous, and thus the regions would have dif-

ferent rates of commitments, whether or not there are differences of

incidence.

Krout (1938) has offered the suggestion that the schizophrenic pat-

tern of rates is the result of the greater tendency of the low-income

slum-dwelling populations to produce "frustrations which fixate the

schizophrenic make-up" in the stages of birth and early feeding, while

the frustrations which produce the manic-depressive pattern occur later,

and more frequently in the higher-income populations.

The material gathered in this study, however, fits best with the

explanation of the schizophrenia rates in terms of the social disorganiza-

tion of the areas, which, when combined with certain other factors,

isolates persons to a sufficient degree to contribute to their mental

abnormality. A study of a large number of life histories of schizophrenia

patients committed from the cities involved in this study, reveals typical

patterns of experience which appear to bear a causal relation to the

mental disorder. In a majority of the cases the early childhood was

reported to be normal and without any indications of the schizophrenic

symptoms. These symptoms developed after the isolating factors had

been at work. In most of the cases the isolating factors, which initiated

the process of abnormality, could not be said to be a result of the original

nature of the person, but were due to external factors, beyond his con-

trol.

The typical process begins with the parental oversolicitude that pro-

duces the "spoiled child" type of personality. This is responsible for a

certain isolation from all but the intimates within the family, but it does

not necessarily result in a seclusive type of personality, or a lack of

feeling of sociability for persons outside of the family. The next stage

is persecution, discrimination, or exclusion, by children outside the fam-

ily. This often happens at the time the child begins his schooling. The

other children are naturally unwilling to accept the child at the parents'

valuation, or at the child's self-valuation which results from the parental

treatment. They show their resentment in persecutory treatment. The

2 4 ] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 753

most usual reaction to this persecution is to feel unhappy, but with no

immediate depreciation of establishing friendships. Often the children

try for years to make friends, only to fail because of their inadequate

personalities, or because of the rigid persistence of their status which

received early definition in the community. Eventually there is a resigna-

tion a withdrawal from a hopeless goal. Instead of trying to make

friends, they confine their social activity within their own families, or

take increased interest in reading, music, art, and other solitary activ-

ities. From this time on their interest in sociability declines and they

slowly develop the typically seclusive personality that is characteristic

of the schizophrenic. The symptoms that are associated with this per-

sonality type arise out of the confusion and misunderstanding that is a

consequence of their lack of experience in dealing with others. The

person who has been isolated for years is deficient in knowledge of

human nature, and misunderstands others and is misunderstood by them.

He mistakes unintentional slights for active persecution. He interprets

his own failures as due to interference by others, since he became so

thoroughly convinced by his parents of his own unique superiority that

he cannot imagine that his own deficiencies cause the trouble. Not being

experienced in intimate personal contacts with a large number of other

persons he is deficient in his understanding of the reactions of others,

and responds unconventionally and inappropriately to them. If, as is

the case with many, his upbringing was of a pious or prudish character,

he has missed virtually all knowledge of sex matters, since he was not

exposed to the informal education that most children get from conversa-

tions with each other during their growing years. His attitudes then

are likely to be that anything pertaining to sex is evil and nasty. Since

he is exceptionally fine and good, judging from his parents' behavior

toward him, his sex feelings could not originate within his own nature,

but must result from the attempts of wicked people to poison him, with

drugs, gas, electricity, or thought waves. If he should, however, decide

that these feelings do stem from his own nature, he may conclude that

he is one of the lowest and most depraved persons on earth, and react

by hiding in shame, by desperate efforts to save his soul by violent

religion, or some equally extreme reaction. Similarly other symptoms

which appear fantastic to others can often be shown to be based on mis-

conceptions which could scarcely be avoided by persons so lacking in

normal social experience.

It is not suggested here that the process of "spoiling" children takes

place more frequently in the disorganized sections of the city. What

does vary in the different areas is the reaction of other children to the

overprotected child. In the more integrated communities, the relations

between adults and children are such as to promote some community

cooperation, with the result that sympathy of adults may lead to the

lessening of the natural discrimination against the socially deficient

child. In the slum areas, however, the lack of this cooperation, the mix-

ture of nationalities, the tradition of "toughness" among the delinquent

754 PERSONALITY AND THE BEHAVIOR DISORDERS [24

boys, and such factors, constitute such a barrier to the establishment of

social relations that many find it impossible, and are thus turned down

the path that leads to the psychosis.

Because it is not clear on what basis the types of schizophrenia were

differentiated, it is not possible to make a very satisfactory interpreta-

tion of the different distributions. An examination of the cases on which

these rates were based showed that the catatonic cases are much younger

than the paranoid and hebephrenic at first admission, and that they have

a higher proportion of women. The catatonic group also contains a

much higher proportion of Negroes, though the proportion of foreign-

born is about the same as in the paranoid group. It may be that these

characteristics reflect the group which is more likely to have the conflict

based on religious prudishness and sex stimulation, and that the older,

more mobile paranoid group represents the egocentric failures who can-

not accept the blame for their own troubles. Such a suggestion must,

of course, await further research before much confidence can be placed

in it.

Conclusions

Such research of a scientific character as has dealt with the relation

between ecology and behavior has mainly been concerned with social

disorganization and the consequent forms of personal disorganization.

This disorganization is for the most part a phenomenon of a great

transition. With the opening of new continents following the discov-

eries of the western hemisphere, and with the industrial revolution,

there occurred large population movements, which are still going on.

Such movements break up the social systems that control and integrate

the behavior of persons, so that new, unconventional, and abnormal

types of behavior appear. These abnormalities are not essentially aspects

of city life, or civilized society, but rather of the populations which are

changing from one system to another. There are many successful social

systems among the most simple preliterate peoples, and there are estab-

lished parts of advanced civilized society that have no serious social

maladjustments. The trouble occurs in the middle stages of the process

of change.

The indices of serious abnormality in behavior, then, show a relation-

ship to this kind of transition. Suicide rates are highest in countries

which are becoming industrialized, and particularly in the cities, and

most conspicuously in the highly mobile parts of those cities. Profes-

sional crime is related to industrial urbanization in much the same way.

Mental disorders have such a variety of causes that it is not to be ex-

pected that they should all relate to the same processes, but it is shown

that certain forms vary spectacularly with the degree of social dis-

organization.

The focal points of these developments, the large, expanding indus-

trial cities, have a very regular, though unplanned, process of growth,

24] ECOLOGICAL FACTORS IN HUMAN BEHAVIOR 755

in the course of which certain typical "natural areas" develop. In each

of these areas there is a typical social situation which favors the develop-

ment of the abnormal behavior traits in the ways discussed above. It is

likely that much ecological variation of normal behavior will also be

demonstrated when more research is applied in the direction to reveal it.

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PART VI

SOME OUTSTANDING PATTERNS OF

BEHAVIOR DISORDER

Chapter 25

BEHAVIOR DISORDERS IN CHILDHOOD

By LEO KANNER, M.D.

IT is CUSTOMARY TO INCLUDE under the heading of children's behavior

disorders a vast range of major and minor deviations from vaguely

defined and variously considered norms of general maturation and spe-

cific performances. Textbooks and other treatises dealing with the

psychopathology of childhood (e.g., Homburger, 1926; Kanner, 1935;

Louttit, 1936) are, therefore, of necessity organized collections of a

multitude of diverse disturbances of frequent or rare occurrence, varie-

gated or selective symptomatology, and different degrees of modi-

fiability. Just as pediatric literature occupies itself with every known

departure from ideal physical health at an early age, so do the discus-

sions of abnormal child psychology comprise every known problem of

overt and implicit behavior during the first years of life. These all-

embracing data, concerned equally with items as unrelated as fever

delirium, nailbiting, stuttering, schizophrenia, and cretinism, are held

together by two outstanding factors common to all disorders : the age at

which they are observed and the fact that they form the nucleus of a

complaint.

The Age Factor. Bradley (1937; 1941, p. 2) called attention to

the confusion which has long existed regarding the concepts of child-

hood and adolescence. One often finds, indeed, in statistical studies and

in presentations of case material, persons in the middle or even toward

the end of the second decade of life referred to as "children." On the

other hand, persons who have barely emerged from the first decade are

sometimes, though less often, treated as preadolescents or adolescents.

Potter (1933) stated: "It was found that the term 'children' was used

rather loosely and included patients with ages as high as 16 or 17

years/' Bradley (1937) offered the following suggestion for the purpose

of clarification and uniform recording : "An example which we may well

follow in this regard is that of the pediatrician and the children's hospital

to whom for classification purposes at least the 'child' is an individual

below a definite age level. This age level had best be that which most

nearly coincides with the onset of physiological puberty, and both tradi-

tion and experience suggest the thirteenth birthday . . . This practice

should successfully eliminate the present confusion existing in psychi-

atric research and in the literature."

761

762 PERSONALITY AND THE BEHAVIOR DISORDERS [25

Many articles and monographs devoted to children's behavior dis-

orders are compelled by circumstances to exclude from their scope the

first two or three years of life. Stevenson and Smith (1934, p. 55)

made it clear that most child guidance clinics rarely have an opportunity

to become acquainted with small infants, whose problems, therefore, do

not figure in reports issuing from those sources. This obvious deficit

was remedied by the close collaboration between psychiatry and pedi-

atrics, which was first instituted at the Johns Hopkins Hospital in 1930

and has since then spread to a number of medical teaching centers

(Kanner, 1932; Clarke and Jensen, 1941).

The students of normal and educational psychology have realized that

"childhood" is a collective term, covering brief life periods of remark-

able difference. They investigated the range of performances in succes-

sive years, so that at the present time expectations for any given age can

be assessed with reasonable accuracy through a variety of tests. These

insights have so far not been carried over consistently to behavior devia-

tions. Child psychiatrists have rarely focused their attention on limited

sectors of childhood. Psychoanalysis, it is true, assigns to each stage of

infantile development a specific state of an hypothecated unconscious

but has not succeeded in correlating convincingly the personality diffi-

culties of each age group with the postulated metamorphoses of the

unconscious.

The So-Called Period of Resistance. Toward the end of the

second and at the beginning of the third year of life, children acquire

normally the meaning and application of negation. This feature has been

so commonly observed that many investigators felt justified in speaking

of this age as the period of resistance or remonstrance (Levy and

Tulchin, 1923; 1925; Reynolds, 1928; Busemann, 1928). Benjamin

(1930; 1941) saw in its manifestations and management a most impor-

tant factor in the development of childhood neuroses. According to

Benjamin, the basic disturbance underlying unusually strong or pro-

tracted resistance consists of a child's failure of adaptation to his en-

vironment, due to insecurity and anxiety. The child's difficulty of

adjusting to the task of growing into relationships with other people and

accepting the values set by them leads to a state of disorientation, hostile

refusals and isolation, with aversion to cleanliness and to the acquisition

of functions commensurate with his age. Hence, for example, come the

persistence of enuresis and disorders of speech. This failure of adapta-

tion leaves three possible avenues open to the child: developmental

standstill, even to the point of regression to a previous stage of existence

in which there was a greater feeling of security; introversive turning

away from reality to find consolation in thumb-sucking, masturbation,

and rhythmic body movements; and spiteful rebellion, resembling the

fluttering of a caged bird or the bewildered agitation of an adult in a

panic situation. Out of the latter mode of reaction arise feeding prob-

lems, vomiting, rebellious wetting and soiling, destructiveness, and

25] BEHAVIOR DISORDERS IN CHILDHOOD 763

temper tantrums. A neurosis is characterized by Benjamin as the un-

naturally prolonged duration of the period of resistance and has its

origin in a combination of social contact disturbances, partial inhibition

of psychic development, inner insecurity, and faulty training. Because

of the etiologic significance of the period of resistance as the basis for

later neurotic conditions, Benjamin urged early prophylaxis and treat-

ment not of the symptoms alone but of the total person.

Prepubescence and Pubescence. The termination of "childhood/'

coinciding with the onset of menstruation in girls, the first seminal

emission in boys and the appearance of the so-called secondary sex char-

acteristics in both groups, has sometimes been referred to as a second

period of resistance because of simultaneous manifestations of a critical

and often resentful attitude toward adults and their standards (Hetzer,

1927; Ruppert, 1931). Progressive emancipation from the home, reach-

ing out into the community, being sucked in by the community, problems

of social, sexual, and theologic orientation offer many possibilities for

friction and inner conflict. There has been a tendency in psychiatric

literature to emphasize similarities between pubescent groping and the

essential features of schizophrenia. This trend, expressed most skilfully

by Cosack (1933), is part of a habit, now gradually declining, of corre-

lating too readily the thinking of children, "primitives" and schizo-

phrenics. Recent ethnologic studies and an excellent investigation of

children by Despert (1940) have sensibly and factually demonstrated

that the fundamental differences outweigh the resemblances by far.

On the whole, psychiatric occupation with the age of pubescence has

been limited to inquiries into the occurrence of psychotic conditions dur-

ing this phase. The monographs by Wille (as early as 1898), Kliene-

berger (1914), and Pappenheim and Gross (1914) are classical ex-

amples. There is general agreement that puberty is a critical age from

the point of view of personality development and more especially from

the point of view of incisive psychopathologic departures.

The Complaint Factor. Besides age, the complaint factor is the

only other common denominator in the consideration of behavior dis-

orders. Its significance has been pointed out by Meyer (1928) and

Kanner (1933a; 1941). Acquaintance with any form of behavior diffi-

culty is made possible by the fact that the patient himself, members of

his family, neighbors, friends, teachers, employers, physicians, courts,

or social workers are sufficiently disturbed to call for expert assistance.

The complaint is an entering wedge, a starting point for planned investi-

gation and treatment, the admission ticket to the psychiatrist's office. It

is always an indisputable live reality which offers itself for a study of its

intrinsic meaning, genetic-dynamic background, relative nuisance-value,

diagnostic reformulation and therapeutic management.

THE COMPLAINT AS A BASIS FOR STATISTICAL STUDIES. All valid

statistics in the realm of child psychiatry, with the exception of recorded

764 PERSONALITY AND THE BEHAVIOR DISORDERS [25

test results, are derived from indices of the complaints with which chil-

dren are brought to clinics, juvenile courts, and their equivalents.

Attempted statistics of "traits" have proved unyielding because of the

inability to come to terms about generally acceptable and unequivocal

definitions. This becomes especially evident in the most ambitious and

painstaking statistical study of children's behavior disorders by Ackerson

(1931), whose exemplary figures regarding complaints contrast sharply

with those regarding the far less concrete and more controversial evalua-

tion of traits and attitudes. Enuresis, regardless of all variables of

etiology and psychodynamics, can be studied statistically as enuresis,

stealing as stealing, and blinking as blinking. But "neurosis," "nervous-

ness," "neuropathy," "aggressiveness" are concepts still too diffuse and

open to arbitrariness to lend themselves for clear numerical depositions.

CLINICAL SIGNIFICANCE. Complaint is not synonymous with symp-

tom. As given to a carefully inquiring and listening examiner, it affords

a vivid picture of the disturbing behavior of a specific child and the

reporter's attitude concerning the child and his behavior. The complaint

thus immediately leads the clinician to an awareness of relationships

and life situations which goes far beyond the recording of detached

symptoms and directs his curiosity to definite causative and curative

possibilities. Expressions, during the recital of the complaint, of parental

excuses, feelings of guilt, accusations, hostility, commiseration, and

anxiety furnish valuable clues to the understanding of the basic diffi-

culty.

CULTURAL IMPLICATIONS. Behavior which is undesirable and gives

cause for complaint in one culture is not necessarily regarded as dis-

turbing in another culture. There are types of behavior which in our

time and civilization create parental anxiety and figure in the current

lists of psychopathologic performances, whereas at other times and in

other civilizations they either go unnoticed or are even encouraged as

signs of normal development. Thumb-sucking is an example of the first

category. It was not considered a problem anywhere until late in the

nineteenth century, when Lindner (1879) warned against its effects on

the formation of the upper jaw and emphasized its hedonic origin. It

became the object of much parental worry when the orthodontists de-

clared it to be the main cause of prognathism, hygienists cautioned that

it introduced pathogenic germs into the oral cavity, and Freud (1905)

spoke of it as the earliest manifestation of oral eroticism. In no other

culture is there any objection to thumb-sucking. In our own, a number

of medieval artists depicted children and angels with thumbs in their

mouths to give them the appearance of serene placidity (Ghirlandajo in

Adoration of the Magi, Credi, Lippi, Borgognone, della Robbia see

Bragman, 1931).

Heterosexual play among children is dreaded in our culture. Malin-

owski (1929) reported that it is good-naturedly condoned among the

Trobriand Islanders. ^Masturbation was for nearly two centuries

25] BEHAVIOR DISORDERS IN CHILDHOOD 765

abhorred as injurious to the development of body and mind as a result

of the warning by Tissot (1760), Hufeland (1797), and Lallemand

(1836). Present-day psychiatry tries to undo the harm done, not by

masturbation itself, but mainly by those unfounded scares. Parental

admonitions which prophesy insanity for a masturbating child are today

considered as much of a "behavior problem" in need of correction as the

child's masturbation. Q

Classification

The manifoldness and complexity of behavior disorders have made

systematic grouping extremely difficult. We know today that even

Kraepelin's famous classification of adult psychoses has failed to settle

matters. We know that the various dichotomies and trichotomies of

mankind offered in explanation of tendencies to certain forms of reac-

tions (for example, Jung's personality types, Kretschmer's types of

body configuration, Jaensch's types of eidetic imagery) are in the main

oversimplications hardly ever applicable to everyday clinical work. This

is especially true of children because personality is still in statu nascendi

and any cataloging therefore can at best be anticipatory rather than

conclusive.

There are, on the one hand, distinct nosologic entitities, such as

juvenile paresis or cretinism, which are amenable to a clear-cut, exclu-

sive diagnosis. There are, on the other hand, innumerable problems of

behavior in infancy and childhood which cannot be pressed into any

categorical system without doing violence to the uniqueness of the con-

stellation in which they occur.

Grouping Based on Complaints or Symptoms. It is, therefore,

not surprising that a classification of the sort applied to most other

sciences has never been attempted in child psychiatry. Many clinics and

monographic presentations are satisfied to index and sort out leading

complaints and bring them under some kind of major headings, such as

delinquency, habit disorders, speech difficulties, fear reactions, and many

others. But even this cannot be carried out consistently, since other

headings, such as feeblemindedness or organic brain disease, rely on the

diagnostic reformulation of the complaint rather than on the complaint

itself. Brown, Pollock, Potter, and Cohen (1937) offered such a "psy-

chiatric classification of problem children/' which has been officially

approved by the Committee on Statistics of the New York State Depart-

ment of Mental Hygiene. This outline distinguishes between ten "prin-

cipal groups": (1) mental deficiencies; (2) psychoses; (3) psycho-

neuroses and neuroses; (4) convulsive disorders, including epilepsy;

(5) behavior disorders with somatic disease or defect; (6) psychopathic

personalities; (7) educational disabilities; (8) primary behavior dis-

orders ("i.e., not secondary to other groups in this classification") ; (9)

social problems; (10) other problems.

;66 PERSONALITY AND THE BEHAVIOR DISORDERS [25

It is evident that such a classification, though doing fair justice to

practical needs, is full of inconsistencies, brought about largely by over-

lapping, duplication, and a certain degree of arbitrariness which is par-

ticularly implied in the subdivision of "primary behavior disorders."

The four subheadings are : Habit, personality, neurotic, and conduct dis-

orders. Many of the enumerations under each title could be easily inter-

changed. A group of experts would be hard put if asked specifically to

indicate under which topic fears, day dreaming, disobedience, habit

spasms are listed by the authors.

Similar difficulties exist with regard to the grouping which Kanner

(1935) has used in his textbook. He divided the material into three

main classes: (1) personality disorders forming essential features or

sequels of physical illness; (2) personality disorders expressing them-

selves in the form of involuntary part-dysfunctions; (3) personality dis-

orders expressing themselves clearly as whole-dysfunctions of the indi-

vidual. Here, again, definite allocation is sometimes rendered difficult

by combinations involving two or even all three of these categories.

Grouping Based on Other Principles. The use of generic terms

has created even greater confusion. There has been a tendency to

differentiate between personality problems and behavior problems (Payn-

tor and Blanchard, 1929), personality problems and conduct problems

(Louttit, 1936), personality problems and conduct problems as sub-

species of behavior problems (Ackerson, 1931). Ackerson spoke of con-

duct problems as those which are usually socially disturbing, while

personality problems are more specifically related to the individual him-

self. Louttit, proceeding on a similar principle, had two types of conduct

problems ("direct primary behavior problems") : those of limited social

significance and those of serious social significance (delinquency). He

had also two types of personality problems ("indirect primary behavior

problems") : actively aggressive behavior and submissive, withdrawing

behavior. All such divisions necessitate artificial definitions. There is,

after all, no behavior, problematic or otherwise, which is not intimately

linked with what everyone regards as "personality."

Howard and Patry (1935) devised three groups of "reactive dis-

orders on the basis of emotional, situational, habit-training and per-

sonality maladjustments" : (1) habit training problems ; (2) aggressive

or protest behavior; (3) submissive or recessive behavior. The reasons

given for this grouping are inadequate.

The Variety of Disorders Defies Rigid Classification. This criti-

cism is in no way to be construed as directed against the authors who

have courageously attempted to present the material in orderly fashion.

It is the subject matter itself which, because of its multifariousness, is not

accessible to pigeon-holing. If a child bites his nails, day dreams, blinks

his eyes and disobeys his parents, he would, according to Howard and

Potter (1937), present habit, personality, neurotic, and conduct dis-

25] BEHAVIOR DISORDERS IN CHILDHOOD 767

orders at the same time. The whole issue then becomes a matter of

preferential terminology.

It would be ideal if children, instead of their behavior, could be

grouped. But this would lead to complete chaos and leave the door wide

open to unscientific name-calling. Who is a neuropath, a psychopath, a

neurotic child, a delinquent? Such terms, though applicable at times,

have much too often been used as swear words rather than well-founded

diagnoses.

Motivation

Not until the beginning of this century did the whence and why of

children's behavior disorders become a matter of psychologic and psy-

chiatric curiosity. Unless there was obvious mental deficiency or gross

organic disease, undesirable behavior was popularly ascribed to badness,

mischievousness, or outright depravity, to be handled, mostly through

punitive measures, by the parental and educational disciplinarians. Most

psychologists and physicians were, if at all, interested in abnormal child

behavior only to the extent of nosologic description. The German text-

book of child psychiatry by Ziehen (as late as 1926) and the Italian

textbook by De Sanctis (1925) had nothing to say about etiology; De

Sanctis went so far as to ridicule the modern direction toward "clinical

individualism" and washed his hands of "the intimate investigation of

psychodynamics."

However, during the past forty years, the study of motivation has

made considerable progress. Two principal trends have developed, which

still exist side by side. One might speak of them as monopolistic theories

and pluralistic considerations.

Monopolistic Theories. The monopolistic theories have in common

the urge to refer all behavior disorders to one specific set of etiologic

factors, to disregard or minimize the importance of all other factors, and

to build up "schools" or "systems" on those exclusive premises. One

such school, which made dysfunctions of the endocrine glands responsible

for all psychopathology of childhood, has never gained wide recognition ;

discourses about "the glands of destiny" and "the glands regulating per-

sonality" have for a time captivated the popular book market but failed

to impress the profession. Another school, founded in Germany by the

Jaensch brothers and making behavior and misbehavior dependent on

eidetic imagery, has never taken root in this country. Beginning with a

few factual observations and experiments, most clearly summarized in

English by Kliiver (1931), E. R. Jaensch, one of the two brothers,

became more and more inextricably involved in abstruse philosophic

problems of eidetically determined Weltanschauung and allowed his

"system" to degenerate into a justification of Nazi ideology.

Three monopolistic schools, however, have made considerable inroads

on educational and clinical work with children, especially from the point

768 PERSONALITY AND THE BEHAVIOR DISORDERS [25

of view of investigative and therapeutic "approaches" to problems of

behavior.

PSYCHOANALYSIS. The psychoanalytic theory has gained a tre-

mendous foothold. It postulates the existence of an unconscious, sub-

divided into super-ego, ego, and id, the interrelation of which determines

personality formation and behavior. Freud (1905) has set down a

course of unconscious infantile sexuality, beginning in earliest infancy

and spread over the entire period of childhood in successive stages

(narcissism, pregenital organization mainly oral and anal, sex curi-

osity with development of the castration complex or penis envy, Oedipus

or Electra complex, latency period, and pubescent genital organization).

Culturally unacceptable impulses are "repressed" by the ego and "sub-

limated" (diverted into socially useful channels) by the super-ego, the

equivalent of "conscience" and the representative of the parent ideal. A

child may become caught and "fixated" at any stage, or even "regress"

to it at a later time. All psychopathology is viewed as emerging from

the failure of smooth, scheduled progression of infantile sexuality.

Psychoanalysis was first applied to children by Freud himself (1909)

in the case of a "phobia" of a five-year-old boy. Freud felt that this

experiment "fully confirmed" his theories derived from the retrospective

analysis of the symptoms and dreams of adults. Since then there have

been many contributions to the psychoanalysis of children. Freud's

daughter, Anna (1925, 1931), and Melanie Klein (1932) are the best-

known representatives. Criticism of the theory of infantile sexuality has

arisen not only from nonpsychoanalysts (Sachs, 1926; Kanner, 1939)

but also from the ranks of the analysts themselves (Horney, 1939).

INDIVIDUAL PSYCHOLOGY. Adler, seceding from Freudian psycho-

analysis, was led by a study of organ inferiority (1907) to the observa-

tion that there seems to be a tendency to compensation or overcompensa-

sation on the part of an inferior organ system. He broadened this

observation into the theory that all personality difficulties have their

roots in a feeling of inferiority and insecurity derived from physical

handicaps, or from clashes with the environment which interferes with

a person's need of self-assertion and desire for power. Adler came to

view children's behavior disorders as attempts at overcompensation for

deficiencies, supplying the child with tools intended to make him the

center of attention and to govern the family. Adler's theories have exer-

cised a marked influence in the field of education. Besides Adler him-

self (1924), Wexberg (1926, 1928) has been their strongest exponent.

BEHAVIORISM. Watson's behaviorism (1919), leaning strongly on

Pavlov's work with the conditioned reflex, was applied to children by

Watson himself in his classical observations of infants at the Johns

Hopkins Hospital. His system of psychology, disregarding the data of

introspection, refusing to have anything to do with the concept of con-

sciousness, reduced all human behavior to an exclusively neurophysi-

25] BEHAVIOR DISORDERS IN CHILDHOOD 769

ologic relation of stimulus and response. Watson (1928) set forth those

principles somewhat radically in a book on child training, which has for

several years enjoyed enormous popularity among the laity. However,

in clinical work with children's behavior problems, the application of

behaviorism has not found a sufficient number of supporters. The very

fact that Watson, in his programmatic writings, did not even by implica-

tion allude to the intelligence factor, makes his system impracticable in

a large portion of psychopathologic disorders.

Pluralistic Considerations. The monopolistic approaches to the

study of personality disorders have undoubtedly made significant con-

tributions. Every one of them has started out with a few novel observa-

tions of facts. But these discoveries, valuable in themselves, were allowed

to serve as prejudicial motivations.

Other investigators, unwilling to narrow the scope to any one set of

facts or theories, have, under the leadership of Adolf Meyer (1929;

Kanner, 1933b), kept in closer touch with the plurality of factors and

occurrences as they are found to exist in real life. Shying away from

preordained simplifications of complexities, they bent their efforts in the

direction of deriving their understanding of behavior from the facts and

combinations of facts as they present themselves to the observer, instead

of forcing realities into any kind of decreed interpretations. This point

of view has sometimes been wrongly termed eclectic. Eclecticism de-

notes a selective nibbling from various systems and schools. Psycho-

logic pluralism does not select but looks for, accepts and includes every-

thing that is factual.

Pluralistic considerations have resulted in the recognition that chil-

dren's behavior disorders may have their origin, singly or in a variety

of mixtures, in different types of factors : physical, intellectual, emotional,

situational, and constitutional.

PHYSICAL FACTORS. Lurie (1935) made an eloquent plea for the

physical examination of every child who presents problems of behavior.

His analysis of 1,000 cases clearly indicated in approximately 75% the

somatic involvement at least as a contributory feature.

Some authors, it is true, gave prominence, sometimes exaggerated,

to specific somatic functions in relation to abnormal behavior in general

or to circumscribed disorders. A few examples only can be cited here.

Orton (1925; 1937) has made a special point of handedness-eyedness

conditions in speech pathology, especially stuttering, and reading and

writing disabilities, which he ascribed to a confusion in hemispheral

dominance; he suggested that changed handedness and split laterality

(right-handedness and left-eyedness or vice versa) create a disturbance

in the normally one-sided, contralateral cerebral hemisphere lead (left

in right-handed and right-eyed people, right in left-handed and left-eyed

people). German authors have paid much attention to the patterns of

the capillaries around the nailbeds as indicators of immaturity and other

abnormalities of personality and behavior (Schiller, 1934). Recently

770 PERSONALITY AND THE BEHAVIOR DISORDERS [25

much has been made of electroencephalographic designs found in "prob-

lem children" (Jasper, Solomon, and Bradley, 1938) ; the findings are

not conclusive and await comparison with the brain waves of a sufficient

number of normal children. There is a tendency, notably in England, to

assign particular importance to hypoglycemia (low blood sugar content)

in attack disorders, such as fainting spells, night terrors, and migrainous

attacks (Henderson and Gillespie, 1932). Studies have been made of

correlations between allergic phenomena and behavior deviations

(Chobot, Spadavecchia, and De Sanctis, 1939; Forman, 1939).

These experimental studies are supplements to the universal clinical

experience that body functioning and behavior cannot be considered

separately, since they are fused in any number of ways.

Behavior and personality development can be profoundly affected by

organic brain disease or disordered functioning of the glands of internal

secretion. Transitory clouding of consciousness with disorientation and

hallucinatory episodes occurs in the course of infectious conditions, intoxi-

cations and nutritional defects. Many other ailments exercise a direct

influence on mood and performance ; one need only think of the apathy

of the child with cardiac illness, the irritability of the child suffering from

eczema, or the stealing of food of a diabetic child on a rigid diet (Shirley

and Greer, 1940). Sometimes the behavior is linked intimately with the

physical condition as an immediate cause. At other times the illness acts

as an abnormal situation to which some children react in an unwholesome

manner, often under the impact of injudicious management of the sick

child on the part of the parents or the physician. Some authors go so far

as to speak of "iatrogenic" (physician-determined) behavior disorders of

children (Kanner and Lachman, 1933).

THE INTELLECTUAL FACTOR. Since the introduction of standardized

psychometric rating, it has become increasingly clear that the degree of

intellectual endowment constitutes a significant criterion in the evalua-

tion of certain aspects of behavior difficulties. A minus in cognition,

expressive capacity, and judgment can be an obstacle to satisfactory

adjustment. Severe feeblemindedness of and below the low-grade moron

type carries with it invariably a lack of ability to conform to the average

standards of training in every existing culture. Adaptation of the higher

grades of intellectual inadequacy, often not even recognized as such in

simpler societies, depends to quite an extent on the competitive demands

made on the children. Such demands come in our society when legal

regulations require school attendance and a retarded pupil's scholastic

failure creates unhappiness, frustration, and insecurity. Those feelings,

in turn, may bring about intense dislike of school, offensive behavior in

the classroom, truancy and, in its wake, various forms of delinquent

behavior. Reports from juvenile courts are all in agreement about the

large contingent of high grade feebleminded and borderline children.

Osgood and Trapp (1936), to quote but one example, found among 400

juvenile delinquents only 18% boys and 17% girls of normal intelli-

25 ] BEHAVIOR DISORDERS IN CHILDHOOD 771

gence, and 21% boys and 29% girls definitely feebleminded; in other

words, as many as 61% boys and 54% girls belonged to the intermediate

group. Lurie (1937) found that among 225 children with IQ between

80 and 89, "the intellectual subnormality was directly responsible for the

behavior difficulty presented by the child" in 18% of the cases, while of

a large group of 1,000 mental defectives the intellectual level was causally

related to the behavior disorder in only 3.8%. "For this reason/' Lurie

concluded, "it is of extreme importance to recognize the role that sub-

normal intelligence may play in the causation of incorrigibility, delin-

quency, criminality and many other forms of social behavior."

Some psychoanalysts have of late propounded the theory that in

many, if not all, instances feeblemindedness, far from being an irre-

versible deficiency, has its origin primarily in an "emotional blocking"

of potentialities possessed by the individual, thwarted by unconscious

mechanisms and capable of being released by psychoanalytic procedure.

Clark (1933) thus expressed this theory: "The general distribution of

libido is such as to restrict the dynamic forces available for intellectual

use." At present, the idea of the emotional background of intellectual

defect is promulgated largely by the staff of the Southard School at

Topeka, Kansas.

THE EMOTIONAL FACTOR. It is difficult, if not impossible, to study

and discuss emotional (affective) happenings without taking into account

(1) the individual involved and (2) the situation which gives rise to

the happening. We have fortunately got away from the academic arm-

chair method of dealing with emotions as if they were entities existing

in their own rights. Emotions are responses to environmental influences

and at the same time signs of what goes on in the responding person.

The meaning and understanding of any sort of emotional behavior are

determined fundamentally by the setting in which it occurs, the manner

in which a person is involved or feels that he is involved, his previous

experiences with similar situations, his previous reactions to similar

situations, phylogenetically determined avenues of response, social con-

ventions and individual peculiarities.

Children's emotional reactions can manifest themselves to the observer

(1) through the type of overt behavior; (2) through visceral participa-

tion; (3) experimentally, through the method of play investigation.

The general "affective tone" is in the main easily recognized as calm-

ness, pleasure, displeasure, irritability, excitement, or perturbation.

Single emotional episodes may be normal, natural, serviceable reactions ;

thus the realization of danger is almost always connected with fearful

avoidance or shrinking, obvious injustice is met with anger in the social-

ized form of righteous indignation, parental cruelty may encounter rea-

sonable resentment of unreasonable authority. Unusually strong reac-

tions are still to be considered normal if they are commensurate with

an unusual situation: marked excitement, differing from the child's

usual behavior, before a birthday party or as part of the Christmas

772 PERSONALITY AND THE BEHAVIOR DISORDERS [25

anticipations, profound grief following the loss of a parent, or fear of

the ragman who has been presented to the child as a dangerous

abductor. Abnormal reactions are out of proportion with the situation

either in intensity (sweeping, uncontrolled dramatic outbursts, such as

breathholding spells, temper tantrums, or panic), in terms of observable

relationship (tics or stuttering which have long been detached from the

originally responsible setting), or in the sense of bizarre, incongruous

behavior which cannot in any way be accounted for situationally (as in

schizophrenia).

Visceral participation is a normal concomitant of all emotional re-

sponses. One may roughly distinguish between three degrees : ( 1 )

physiologic participation, present at all times but usually so unobtrusive

that it can be ascertained only through specific methods: (2) near-

physiologic participation, still within the limits of normal fluctuation,

but often creating discomfort or embarrassment; gastric disturbances

with nausea in excitement, marked blushing, the proverbial examination

diarrhea are typical examples; (3) pathologic visceral participation

makes up a large portion of behavior disorders in which organ dys-

functions play a part. It is responsible for psychogenic palpitation,

respiratory disorders, pallor, fainting, anorexia, constipation, vomiting,

diarrhea, enuresis, headaches, and some of the hypochondriacal sensa-

tions. These somatic manifestations of undesirable behavior may be

considered as deriving from normal visceral participation (a) through

unusual and habitual intensification (from accelerated pulse rate to rapid

heart beat, from gasping to breathholding, from mild gastric discomfort

to vomiting) ; (b) through intentional utilization in order to gain coveted

attention; (c) through automatization, when the physiologic con-

comitants become so frequent and detached from the original emotion

that they no longer serve as specific signals in response to circumscribed

settings (tics, enuresis).

Until a few years ago, very little could be done to ascertain from

children directly how they felt. Their feelings could be deduced only

from their performances. Ordinary conversational inquiry did not suffice

to elicit a telling account of what went on in the children. New ways

had to be found in order to "get at" them. Lowrey (1937) wrote:

"Most of us who have been long in children's work began very early to

use toys, pictures, drawings and modellings as a means of uncovering

children's wishes, fantasies, hostilities, jealousies, and transference."

The first systematic efforts to use play as a means of disclosing children's

emotional life came from psychoanalysts (Hug-Hellmuth, 1913; A,

Freud, 1925; Klein, 1932). The lead has been taken up by many child

psychologists and child psychiatrists, who developed three principal

methods : standardized, spontaneous, and situational play methods.

The standardized method was introduced by Levy (1936, 1937a),

who, setting out to study problems arising from sibling rivalry, tried to

"shape the play situations into essentially similar forms by utilizing the

same play material and the same stimuli words." Levy confronted the

25] BEHAVIOR DISORDERS IN CHILDHOOD 773

child with an amputation doll, a metal doll which could be dismembered

and restored. This doll represented the child's mother ; two other dolls,

made of celluloid, were identified with the patient himself and his brother

or sister being held and "fed" by the mother doll. The child's behavior

in this setting (moving toward the dolls, dropping or denting, throwing

or hitting, crushing or biting the baby doll, doing something unkind to

himself, turning against the examiner, moving away from the group)

was interpreted by Levy in a definite, stereotyped fashion.

Despert (1938) studied "aggressiveness" by giving children a knife,

locking them in a room, telling them to scrape a piece of cardboard

and interviewing them immediately after they had been left unobserved

for an hour. Their responses to certain questions were then interpreted

as indicating certain emotional attitudes.

"The problem of the child's love relationship with its father and

mother and siblings" was studied by Bender and Woltmann (1936) by

means of standardized puppet shows on a definitely psychoanalytic basis.

The spontaneous play method ushers the child into a room in which

there is a variety of toys, observes his attitudes and actions in relation

to the toys and the examiner and draws its conclusions therefrom. As

Rogerson (1939) stated, the child "could make as much noise as he

liked, say and do what he liked, and in fact do anything except break

the windows or lights." Allen (1934, 1937, 1939) stressed the value of

this type of play as providing the child with familiar tools to "relate

himself" to the examiner: "Into the play he will bring the reactions and

feelings common to his relations outside . . . Interpretation then is in

terms of the present meaning rather than in terms of the past."

The situational method has been most consistently employed by Conn

(1939a, b), who described the "play interviews" as follows:

It is not a fixed technique but an opportunity for the child to

express himself and at the same time to reveal to himself the role

which he has played in his illness. This is accomplished by providing

an opportunity for the child to speak for each of a number of dolls,

and simultaneously to view all that is going on while he is actively

participating in an intimate discussion of his own attitudes . . . Toy

furniture and dolls representing various characters (parents, siblings,

teachers, etc.) are used during the play interview, and various scenes

are arranged by the physician as upon a miniature stage. In every

case the realities of the child's life situation suggest to the physician

what play experiments to set up.

The study of the emotional life of children has doubtless been greatly

enhanced by the methods of play investigation.

THE SITUATIONAL FACTOR. Emotions, whether they be normal,

near-normal or abnormal, are responses to situations. In child psy-

chology and psychiatry, the motivating values of a child's environment

have been recognized from the earliest days. The influences of training

and example have been stressed from time immemorial. There is now

774 PERSONALITY AND THE BEHAVIOR DISORDERS [25

general consensus that children's personality development and behavior

are determined not only by the things that are done to them but also,

sometimes directly and sometimes more indirectly, by the personalities

and attitudes of the people around them. In fact, the very presence of

a child in a home, a play group, or a classroom creates a situation to

which the others react in a variety of ways which in turn reflect on the

child's own responses. Thus a child's unusual size, obesity, neurologic

or orthopedic handicaps, impaired vision or hearing, chronic skin erup-

tions, or other noticeable physical shortcomings lend themselves to re-

marks by playmates, need for medical care and parental financial sacri-

fice and special educational arrangements, all of which cannot help but

constitute a situation of incisive importance for the child.

The principal environmental settings which motivate children's be-

havior and often interact can be roughly divided into three categories :

the home, the school and the neighborhood. It is impossible in the

scope of this presentation to set forth more than a brief enumeration,

with a sampling of the vast literature, of the potentially pathogenic

factors referable to a child's environment.

Throughout childhood, the home is the nucleus of a child's social

life; there he emerges by degrees from the passivity of the neonatal

period to a stage in which he becomes a domesticated member of the

household and is gradually prepared for the tasks of communal adjust-

ment. Difficulties may arise from a number of features, none of which

is always a breeder of trouble but each of which can alone, or in com-

bination with other factors, play havoc with a child's happiness, security,

or adequate habit formation. The effects of emotional problems of

parents and of parental dissensions on the development of abnormal

behavior patterns of children have been reported by many authors.

Myers (1929) has shown how parental suspiciousness and feelings of

superiority can be handed on to the offspring. Levy (1932) made a

survey of children's problems in overprivileged and underprivileged

families ; he found in the first group a predominance of temper tantrums,

negativism, and "introversion," and in the second group a greater inci-

dence of stealing, lying, and incorrigibility. The consequences of broken

homes have been variously evaluated; most investigators ascribe major

significance to the dissolution of the home as a motivating or at least

contributing force in the origin of behavior disorders ; Silverman (1935),

in a statistical study, concluded that there is no significant (statistical)

relationship between the broken home and the behavior of children com-

ing from such homes.

Of far greater etiological importance is the relationship between

parent and child. Levy (1937b) reported a number of illustrative cases

which show the untoward results of a lack of maternal affection. He

demonstrated three groups of reactions to what he called "affect hunger" :

one in which there were pathologic residues due to an extreme deficiency

in maternal love; one in which the restoration of maternal love had

marked therapeutic effect; and one in which specialized difficulties in

25] BEHAVIOR DISORDERS IN CHILDHOOD 775

social relationships were found to be "derivatives of a primary affect

hunger." This lack of affection, sometimes overcompensated by over-

solicitude, was found by several authors to be based on rejection of the

child by his matrimonially frustrated mother (Newell, 1934). Case

material from child guidance clinics and juvenile courts has brought to

light the great influence on children's behavior of parental overprotection

and overindulgence ("spoiling"), hostility, neglect, and exaggerated edu-

cational ambitions and expectations. Many studies exist with regard to

the bearing of a child's position in the family in order of birth on the

one hand and tendency to behavior difficulties on the other hand. The

only child has been the object of special curiosity. According to

Campbell (1934), "Stanley Hall is said to have considered being an only

child a disease in itself." Recent studies have been rather contradictory.

While some declared only children to be physically inferior and given to

restlessness and dissatisfaction, others could not agree that they were in

any way different from other children. Blatz and Bott (1927) learned

that only children had the best behavior rating among 1400 Toronto

school children. The same discrepancy exists in the literature concern-

ing first-born and youngest children. Goodenough and Leaky (1927)

said in conclusion of an interesting investigation that "there is no posi-

tion in the family circle which does not involve, as a consequence of its

own peculiar nature, certain special problems of adjustment."

The relationship between siblings from the point of view of rivalry and

jealousy and behavior difficulties arising on that basis has received par-

ticular attention from Levy (1937a), whose interpretations of the results

of standardized play investigation tend, however, to see sibling rivalry

too readily in everything that a child does.

Next to the home, the school is the greatest and most powerful social-

izing agent. It is a child's protracted experience with competitive living

within a group under direction. But in the course of years, a consider-

able number of difficulties may grow out of the school situation. The

outstanding pathogenic elements are: unhealthy relations to teachers,

unhealthy relations to classmates, physical illness, lack of recreational

outlets, grade misplacement of children with retarded or superior endow-

ment, frequent changes of schools, long absences from school, experience

of failure, and parental interference with the school regulations. The

best discussions of the contributions made by the school to children's

behavior and its deviations come from Wickman (1928), Sayles (1929),

and Cameron (1933).

Neighborhood influences have been investigated largely in connection

with juvenile delinquency. Almost all juvenile courts now have maps of

their districts showing the distribution of residences of the offenders

brought to them. Such maps invariably show at first glance that some

sections are heavily dotted, while others are almost entirely free from

delinquents. Shaw (1929) has shown in his excellent study that disin-

tegrating areas have the highest delinquency rates, that in large cities

these areas are located near the business and heavy industrial sections,

776 PERSONALITY AND THE BEHAVIOR DISORDERS [25

that the delinquency rate decreases in proportion to the distance from

the center of the city ; and that there is a definite correlation with poverty,

overcrowding and absence of recreation centers. Plant (1930) gave a

brilliant account of the effects upon children of crowded living conditions,

which he summed up as follows :

Children living in large families in crowded quarters (and neigh-

borhoods) have presented to us certain traits which run through

much of the entire group. Those which seem very common, very

fundamental and reasonably to be ascribed to crowding are five : ( 1 )

Difficulty in developing a self-sufficient entity or personality. (2)

Destruction of illusions about other people with a consequent diffi-

culty in building heroes and a real personal idealism. (3) Destruc-

tion of illusions about sex, with a concomitant factor that the child

grows to value the physical sexual life per se rather than as a symbol

of idiomatic relationships. (4) A "mental strain" a constant wear

and tear from constantly having to "get along" with other people.

(5) Failure in developing a habit of objectification of self or those

phenomena impinging upon the self.

THE CONSTITUTIONAL FACTOR. While the physical, intellectual, emo-

tional and situational factors are accessible to direct and concrete obser-

vation, the concept of constitution has remained an abstraction and has

not even been clearly and uniformly defined as such. This seeming diffi-

culty is perhaps the greatest tribute to the uniqueness of each human

individual. In the absence of a clear-cut definition, we might say gener-

ally that "constitution" is that which a child has inherited from his

parents plus that which he brings with him into the world as an un-

duplicated experiment of nature, an individual sui generis. Only on this

basis can it be explained that different children react differently to the

same environment. We know that inherent potentialities differ with

regard to attainable size, configuration of the body, physiognomy, and

other characteristics. We are forced to assume that they also differ with

regard to personality difficulties and behavior tendencies, over and above

the inroads made on a child by all the factors discussed above ; even some

of those, notably the factor of innate intellectual endowment, can be

ascribed to "constitution. " Previous attempts to judge constitutional

weakness from so-called stigmata of degeneration have been as fruitless

as later efforts to single out a neurotic or neuropathic constitution or the

habit of speaking glibly of constitutional inferiority or immaturity.

FUSION OF FACTORS. In the clinical study of any child, with or with-

out behavior difficulties, none of the motivating factors can be consid-

ered alone, detached from the others and, above all, detached from the

child. They are all fused in a particular manner. It is this fusion, under-

stood only in terms of the child's biography, which brings about the

constellation of the moment in a developing integrated person. Consti-

tutional uniqueness, health, intelligence, environment, and type of emo-

tional response melt into a oneness, the child under consideration. That

25 ] BEHAVIOR DISORDERS IN CHILDHOOD 777

is why even the finest statistical calculations regarding this or that factor

can never be applied diagnostically, prognostically or etiologically to the

next child who comes along.

Manifestations of Children's Behavior Disorders

In accordance with the great manifoldness of causative factors and the

almost limitless possibility of their combinations, the symptoms, manifes-

tations, or expressions of disordered behavior are very numerous, indeed.

This becomes especially clear if one considers the many functions which

can be impaired : "intelligence/* memory, judgment, thinking, emotional

responsiveness, the routine performances connected with food intake,

elimination and sleep, motility, habit formation, attitudes toward parents,

siblings, teachers and playmates, physical health, attitude toward health,

sense of security, acquisition of self-dependence, regularity of school at-

tendance, truthfulness, respect for property rights, sexual adjustment,

speech, ability to comprehend, reading, numerical and mechanical abil-

ities, and many other items. The differences in degree cannot be empha-

sized enough ; there is a wide range from very severe and sometimes

ominous illness affecting all spheres and phases of performance to minor

and minimal, often only temporary, deviations from "normal" activity.

It is well to remember that perfection is not a human attribute. Just as

even the healthiest child is subject to an occasional cold, sore throat or

bruise, so can and does every child in the course of his first decade

and a half of life at times display forms of behavior which are comprised

under the heading of behavior disorders. A sense of proportion and rela-

tivity is therefore indispensable in the consideration of complaints about

the behavior of individual children. The common minor anomalies have

been well designated by Thorn (1927) as the "everyday problems of the

everyday child."

Behavior Disorders Forming Essential Features or Sequels of

Physical Illness. This group is composed of those disorders which are

intimately connected wtih permanent or transient damage to the body or

selected organs or organ systems.

IRREVERSIBLE STRUCTURAL DAMAGE TO THE CENTRAL NERVOUS

SYSTEM. Pathologic changes of the cerebral tissues are mostly allied

with a loss, deficit or arrest of the mental functions. Congenital malfor-

mations of the brain result in slow and insufficient intellectual develop-

ment and in those personality disorders which go with the existing

somatic handicaps (paralyses, contractures, abnormal motility, blindness,

deafness). The prototypes are: porencephaly a lack of cerebral sub-

stance, "a hole in the brain"; microcephaly unusual smallness of the

brain; hydrocephalus accumulation of an abnormally large quantity of

cerebrospinal fluid in the ventricles or in the subarachnoid space ; amau-

rotic family idiocy or Tay-Sachs disease a widespread degenerative

process affecting the ganglion cells of the entire central nervous system;

778 PERSONALITY AND THE BEHAVIOR DISORDERS [25

tuberous sclerosis or Bourneville's disease very rare, characterized by

multiple sclerotic areas of the cortex and tumors of various internal

organs. Mongolism also belongs in this group, even though the patho-

logic brain condition is not as unequivocally established as in the other

diseases ; it is recognized from a peculiar Mongoloid physiognomy, cer-

tain anomalies affecting chiefly the shape of the head, the eyes, the tongue

and the extremities, considerable hypotonia of the muscles, and a marked

defect in the mental development (Brousseau, 1928).

Acquired brain lesions may affect the child in the sense of complete

or partial standstill of mental growth, a dropping out of functions already

possessed, or a general change of emotional, adaptive, and social re-

activity ("change of personality"), with or without intellectual impair-

ment. In acute illness, there may be a varying degree of reduction of

consciousness, ranging from mild drowsiness and delirium to profound

coma. In the chronic diseases, memory, judgment, comprehension, and

the capacity for verbal communication may suffer. Among the sequels

of brain disease are intellectual inadequacy, epileptiform conditions, faulty

utilization of experience, confusional states, and antisocial trends.

Brain tumor, brain abscess, meningitis, encephalitis, juvenile paresis,

and cerebral trauma are the main such conditions affecting personality

development and behavior. Epidemic or lethargic encephalitis was

plentiful in the wake of the grippe epidemic during the latter part of the

First World War. Jelliffe (1927) stated: "In the monumental strides

made by neuropsychiatry during the past ten years no single advance

has approached in importance that made through the study of epidemic

encephalitis. No individual group of diseased reactions has been as

widely reported upon, as intensively studied, nor as far reaching in modi-

fying the entire foundations of neuropsychiatry in general." Its clinical

manifestations are polymorphous and almost unlimited. Thiele (1926)

distinguished three types of behavior disorders following this disease:

(1) pathogenic, process-determined character changes; (2) reaction

tendencies which had been a part of the patient's original personality

make-up, made dormant by adequate training, and becoming activated

under the influence of the disease; (3) reactive misbehavior arising from

a response to being ill and the closely associated changes in the living

conditions and in the attitudes of the environment. A good general

orientation about the behavior disorders connected with, and resulting

from, this disease is offered by Hohman (1922) and by Bond and Appel

(1931). Symptoms and sequels similar to those of the epidemic form

can also be brought about by sporadic incidents and cases of encephalitis

associated with infectious diseases (measles, chicken pox) and with lead

poisoning.

Juvenile paresis is a disease based on congenital syphilis and the in-

vasion of the brain by spirochetes. The principal features of the mental

disturbance consist of progressive intellectual deterioration, impairment

of comprehension, memory and judgment, habit disorganization, and

emotional instability. Aside from this "simple" form, some children dis-

75] BEHAVIOR DISORDERS IN CHILDHOOD 779

play the "expansive" form with delusions of grandeur or a "depressive"

form. The monograph by Menninger (1936) gives a thorough account

of the disease and the most complete bibliography to be found anywhere.

Cerebral trauma may be due to antenatal injuries about which little

is known except for those which lead to miscarriage, stillbirth or early

death, birth injuries or postnatal head injuries. Schroeder (1929) found

distractibility and overactivity to be the characteristic behavior traits in

the birth injuries. Figures about the frequency and degree of intellectual

retardation vary in the reports from different investigators, because the

neurological handicaps make an exact and sometimes even an approxi-

mate estimation exceedingly difficult. It may be said, however, that the

last two decades have brought considerable hope to birth-injured chil-

dren, who are now much better understood and trained (Rogers and

Thomas, 1935; Lord, 1937). Doll, Phelps, and Melcher (1932) have

published a thorough study of mental deficiency due to birth injury.

The most fascinating and informative presentation of the problem comes

from Carlson (1941), who autobiographically describes his ascendency

from a birth-injured cripple to a respected specialist in the very field of

his own disease ; his book gives an excellent illustration of the problems

met and presented by such children.

The main results of head injuries sustained during childhood were

reported by Bailey (1903) as irritability, temper tantrums, boisterous-

ness, fighting, and unmanageableness, and by Kasanin (1929) as marked

emotional instability, antisocial trends, headaches, and inability to stand

heat and closed-in places.

TRANSITORY CEREBRAL INVOLVEMENT. Another set of psychopatho-

logic disorders, also bound to somatic illness, is more transient and de-

pends on temporary metabolic and toxic brain involvement rather than

on more or less irreparable tissue alterations. Impairment of conscious-

ness is the outstanding feature. It may appear as delirium with confu-

sion, disorientation, fear and hallucinations, as stupor, coma, or febrile

convulsions. Chorea also belongs in this group, though the behavior pic-

ture consists largely of increased sensitiveness and irritability. Manic-

like excitements and other brief psychotic episodes have been observed in

rare instances (Diefendorf, 1912; Davies and Richards, 1931).

THE ENDOCRINOPATHIES. Dysfunctions of the glands of internal se-

cretion are associated with certain physical anomalies and behavior devi-

ations. Congenital deficiency of thyroid secretion in the form of cretinism

goes with a general stunting of growth and mental development. Hyper-

thyroidism, encountered at the age of pubescence, is accompanied by

sensitiveness, excitability, and irritability. Frohlich's syndrome, a pitu-

itary disorder, produces general intellectual and emotional immaturity.

Suprarenal disorders result in precocious sexual development.

Behavior Disorders Expressing Themselves in the Form of Invol-

untary Part-Dysfunctions. A considerable and clinically conspicuous

780 PERSONALITY AND THE BEHAVIOR DISORDERS [25

portion of the psychopathology of infancy and childhood is made up of

localized functional disturbances seemingly limited to a specific organ or

organ system, which is itself healthy in the sense of morphology and

physiology. The disorder is an involuntary part-manifestation of the not

harmoniously functioning totality of the organism, hence it is a disorder

of personality and behavior. Singly, the same symptom may be due either

to structural pathology ("organic''), to personal pathology ("func-

tional"), or to a fusion of both. Differentiation depends on a thorough

investigation of both physical condition and personality.

The relationship between personality and somatic part-dysfunction has

been recognized for a long time. It has been less easy to understand the

type of linkage and the reason why a particular organ has been selected

in the individual instance. A number of explanations has been attempted.

The possibility of intensification and automatization of visceral participa-

tion in emotional reactions has been mentioned above. Anton (1906)

and Peritz (1919) spoke of partial infantilism, denoting that certain

organs did not keep pace with the general evolution of the individual.

Adler (1907) thought in terms of constitutional organ inferiority; the

individual, besides his verbal and gestural language, has an "organ vocab-

ulary" of his own, which is an expression of his struggle to overcome his

organ inferiority and furnishes a clue to the understanding of the choice

of his neurotic symptoms. According to the Pavlovian school (Pavlov,

1928), the organ selection depends on the specific mode of conditioning

which in a given person gives rise to behavior such as vomiting, tics, or

enuresis as a response to certain situations. Others speak of substitution

of emotional difficulties through somatic symptoms. Substitution with no

conscious association of the symptom with a "forgotten" emotionally

loaded situation has been termed conversion, a process by which sums of

emotion become transformed into physical manifestations. The fusion

of personal and organic pathology has in recent years received special

attention by an increasing group of physicians who have set out to build

up a body of what is called "psychosomatic medicine."

Almost every organ system may lend itself for the somatic part-

expression of emotional difficulties. The central nervous system may

respond with headaches, the circulatory system with blushing, pallor

or palpitations, the digestive apparatus with anorexia, constipation,

vomiting, or encopresis, the urinary system with enuresis, the striped-

muscle system with tics, or general motor restlessness. Enuresis, en-

copresis, and tics may serve as examples.

ENURESIS. Involuntary nocturnal or diurnal passage of urine is

usually cited as a typical paradigm of part-dysfunctions of a psychogenic

character. An enormous bibliography has accumulated. From W% to

at the most 30% of all cases were found to result from physical causes.

The others have their origin in faulty training and in personality features

of immaturity, instability, or insecurity. However, we cannot get away

from the observed fact that enuresis is sometimes an isolated habit dis-

25] BEHAVIOR DISORDERS IN CHILDHOOD 781

order in otherwise well-adjusted children. Enuresis is a frequent mani-

festation of early remonstrance ; it has been found at times to be an ex-

pression of jealousy or spite. Attempts have been made to differentiate

between a number of "personality traits" of enuretic children. Bissell

(as early as 1892) divided them into two groups: those who are active

and oversensitive, and those who are slow and phlegmatic. Behm (1923)

had three groups : degenerated, phlegmatic, and excitable. Pototzky

(1924) had four types: (1) the spiteful-uninhibited children, who wet

themselves intentionally to tease the parents and teachers; (2) the shy-

inhibited children whose wetting is an expression of fearfulness; (3) the

restless, absentminded children, who are so easily distracted that they

forget their urinary needs ; (4) the indifferent children, who are not suf-

ficiently concerned to acquire proper urinary control.

ENCOPRESIS. Involuntary defecation of a nonorganic nature is less

common than enuresis. Thorn (1929, p. 102) said: "One can only say

that these cases call for a careful psychiatric examination by the best

qualified person available. And it will often test all his skill and in-

genuity to understand the mental processes at work that result in such

conduct." Shirley (1938) reviewed 70 cases ; 33 of those had IQ of more

than 80. Exceptionally poor home environment and parental over-

solicitude were frequent findings. For the rest, the etiologic factors

varied with the individual children.

Tics. Tics or habit spasms are sudden, quick, involuntary, and repe-

titious movements of circumscribed muscle groups, serving no apparent

purpose. Blinking, grimacing, head shaking, clearing the throat, sniffing,

and jerking the shoulders are the forms observed most frequently. Tics

may be residuals of intelligible actions, originating as defensive move-

ments against some constant irritations, such as a tight cap, tight sus-

penders, long hair coming down in front of the eyes, poorly fitting eye-

glasses, or an itching skin disease. Imitation of others also plays a part

in the etiology. The habit becomes detached from its primary purpose

and is no longer useful in the economy of motility. This detachment or

automatization takes place in a setting of environmental and emotional

stress. The classical monograph by Meige and Feindel (1902) is still the

best presentation of the subject.

Behavior Disorders Expressing Themselves Clearly as Whole-

Dysfunctions of the Individual. Psychologically uninformed people

find it sometimes difficult to believe that organ dysfunctions, such as con-

stipation, vomiting, enuresis, or tics, can represent "behavior/* There is

no such difficulty in connection with the largest group of children's be-

havior problems, which appear obviously and unmistakably as personal

performances. They comprise a wide range and variety of deviations

from acceptable "average" behavior in all spheres of cognition, conation,

and affect. At the risk of being repetitious, it is well to emphasize that

there is considerable fluctuation between "normal" and outright psycho-

782 PERSONALITY AND THE BEHAVIOR DISORDERS [25

pathologic behavior of children. The single deviation is relatively neg-

ligible or relatively severe according to the extent to which it interferes

with the child's own adjustment and well-being, the family's attitude

toward the child, and the established standards of our culture and social

order. A single instance of "stealing" a few cherries from the neighbor's

yard differs essentially from habitual pilfering from stores. A "white

lie" of a child driven into a corner and anticipating excessive punishment

differs fundamentally from false accusations leading to the arrest and

trial of an innocent person. Occasional daydreaming as a spare time

pleasure does not have the serious connotations of obsessive preoccupa-

tions affecting a child's scholastic and social performances.

The following review of the outstanding problems must of necessity

be brief and summary. Wherever possible, the reader will be referred

to the best available sources in the literature.

UNHEALTHY EMOTIONAL RESPONSES. Reactions of jealousy, anger,

and fear are the commonest forms of overt emotional disorders of

children.

The two principal sources of jealousy are the arrival of a new baby

and the practice of contrasting siblings with one another. Its manifesta-

tions are manifold ; they are designed to center parental attention on the

jealous child (Foster, 1927; Levy, 1937a).

Vigorous anger and resentment are expressed by infants in the form of

breathholding spells, later through temper tantrums, and still later less ex-

plosively through sullenness and crossness. Children have a tendency to

react more drastically than adults; this is true even of physical hap-

penings. A child vomits much more readily when ill or as a result of

carsickness ; the chill ushering in a febrile disease may in children assume

the proportion of a full-fledged convulsion. This tendency to explosive-

ness shows itself particularly in the outbursts of anger. The gradual

transition from breathholding with loss of consciousness, sometimes even

associated with convulsive phenomena, to the motor and vocal violence

of tantrums, and from those to less vigorous pouting, is a very instructive

example of the gradually decreasing propensity for emotional explosive-

ness (Goodenough, 1931).

Fearfulness is not an inherent characteristic of a normal and well-

trained child. He learns to recognize real dangers and to avoid them

cautiously. Fear of imagined perils is acquired through faulty education

and parental example. Hagman (1932) found a close correlation between

the fears of preschool children and fears expressed by their mothers.

Jersild, Markey, and Jersild (1933) learned that only a negligible num-

ber of children had real experiences with regard to objects or situations

feared, such as animals, the dark, strangers, or being alone, and of course

no experiences, other than threats or frightening stories, with ghosts,

kidnappers, and the like.

Full-fledged anxiety attacks are not so uncommon in children as the

sparseness of literature would seem to indicate. These occur mostly in

25] BEHAVIOR DISORDERS IN CHILDHOOD 783

the evening or at night and are characterized by sudden terror, palpita-

tions, and acute fear of death. They often begin after an operation,

especially one with ether anaesthesia (Richards, 1932, p. 189; Langford,

1937).

Deep-rooted fear may find an outlet at a time when the child is, as it

were, caught off his guard. It then is expressed in the form of night-

mares and night terrors, which require a study of the fearful dream con-

tents, the child's diurnal preoccupations and fantasies, the environmental

constellation, physical condition, and specific events and experiences

which may have a more or less direct bearing on the child's emotional

difficulties, responsible for the sleep disorder (Strauch, 1919).

DISORDERS OF VERBAL AND GRAPHIC EXPRESSION AND COMPREHEN-

SION. It is a matter of common observation that inherent intellectual

inadequacy ("mental deficiency") is associated with corresponding diffi-

culties in the acquisition of verbal tools for symbol formation and com-

munication. Late onset of speech is followed by deficiencies in both active

and passive vocabulary, and in the ability to learn graphic symbolization

through reading and writing. This difficulty is, roughly speaking, pro-

portionate to the degree of the intellectual defect. Speech does not only

begin at a later age than is usual but articulation, enunciation, gram-

matical construction, ease of expression and the capacity for the grasp

and use of abstractions is impaired in varying degrees.

The development of speech suffers also in cases of certain physical

handicaps. The deaf child lacks the usual avenue for receiving, through

audition, the verbal symbols common in his environment. He has the

choice between mutism and invention of his own verbal representations

("idioglossia"). Neurological diseases affecting the mechanics of the

speech apparatus may seriously affect the intelligibility of a child's

linguistic performance.

Late onset of speech and faulty articulation, especially in the sense of

"baby talk" or retention of an earlier mode of enunciation, occur also in

children of normal health and intelligence.

Stuttering is speech of a halting, hesitating nature, with repetition

of the initial sounds of a word or sentence. Most stutterers experience

no difficulty when they sing or whisper. It has been estimated that nearly

a quarter of a million children in the United States stutter. Boys are

much more frequently affected than girls ; this is also true of the other

disorders of speech. In many children, stuttering is associated with a

history of changed handedness or with "split laterality." There are many

theories about the etiology. It is now commonly agreed that it is the

manifestation of a personality disorder which, in turn, creates further

emotional problems because of self-consciousness and fear of speaking

in anticipation of possible embarrassment. A thoroughgoing discussion

of the subject from many angles will be found in the symposium edited

by West (1931). Other helpful presentations are those by Bluemel

(1930), Travis (1931), Brown (1933), and Orton (1937).

784 PERSONALITY AND THE BEHAVIOR DISORDERS [25

Even though there is consensus about the emotional background of

stuttering, no uniform definition of the basic nature of this background

exists. This is also true of the so-called specific disabilities, of which

reading disability (dyslexia, congenital word-blindness) has received by

far the greatest attention. The others are disabilities in writing, spelling,

arithmetic, and musical appreciation.

Since Hinshelwood (1917), it has become increasingly clear that

many children of normal or even superior intelligence experience an iso-

lated difficulty in learning how to identify written or printed verbal

symbols. This condition, like stuttering, is predominant in boys and has

correlations with the handedness-eyedness question. Like stuttering, it

gives rise to added emotional distress because of the experience of failure

not explicable to the child or to the environment which does not under-

stand his handicap. Specific reading disability is often connected with

difficulty in writing and spelling and with a tendency to reversal of

letters and words in reading and writing ("strephosymbolia"). Methods

have been devised to diagnose and measure through reading indices the

degree of a child's dyslexia, and special methods of remedial reading in-

struction have been worked out (Monroe, 1932; Gates, 1935; Betts,

1936).

Congenital word-deafness is a very rare condition characterized by

the inability of otherwise intelligent children to comprehend the meaning*

of words heard. Deafness in the ordinary sense is not present. Some of

these children were found by Ewing (1930) to be unable to perceive

sounds of a frequency above 256 double vibrations. The patients com-

municate well through gestures but have no understanding of verbal

symbols.

HABITUAL MANIPULATIONS OF THE BODY. No other culture of the

past or present has attributed so much significance to certain habits of

children as does our own civilization. This fact indicates on the one hand

the laudable desire to record, observe and explain behavior in whichever

form it is noted, but on the other hand often furnishes an additional

source of parental worry and anxiety. We have in mind motor habits

which consist of frequent repetitions of movements which serve no other

purpose than that of providing pleasure for the indulging person. Some

of them, such as head banging or noisy grinding of the teeth, may indeed

become quite disturbing. Some were found to have hedonic implica-

tions similar to masturbatory gratification. Olson (1929) divided these

"nervous habits" into oral, nasal, manual, hirsutal, aural, irritational

(scratching), ocular, genital, and facial. Thumb-sucking and nail biting

are the most frequent complaints. Both have been regarded as far more

serious than they really are. That the tide of overemphasis of these

habits is receding, is best indicated by more recent publications, such as

the one by Langford (1939).

ANTISOCIAL BEHAVIOR. Inasmuch as the subject of delinquent be-

havior is fully discussed in the following chapter by Lowrey, it is not

25] BEHAVIOR DISORDERS IN CHILDHOOD 785

necessary to enlarge upon it in this place. The present attitude toward

juvenile delinquency is one of the most eloquent examples of the shift

of public and professional sentiment from impersonal retaliatory "pun-

ishment" to interest in the individual child, the motives of his difficulties

and steps toward his rehabilitation. Even in this reference to another

chapter, the pioneering work of Healy (1915), his life-long effort to

understand and treat the antisocial behavior of children, and his profound

influence on the establishment and trends of modern juvenile courts must

at least be mentioned.

OVERT SEXUAL BEHAVIOR. In our culture every kind of overt sex

behavior of children is immediately viewed as a behavior disorder. If, as

in masturbation, no other person is involved, the complaint is usually

made to physicians, psychologists, or psychiatrists. If the sexual act

implicates more than one person, the performance is classed with the de-

linquencies. Among the delinquency cases disposed of by 88 courts in the

United States in 1930, a total of 2% of the boys and not less than 21%

of the girls were arraigned because of sex offenses, mostly heterosexual.

The age distribution among children under 14 years was as follows :

Age Boys % Girls %

Under 10 years 2 11

10-11 years 1 9

12-13 years 1 15

The commonest complaint with regard to children's sexual perform-

ances is that of masturbation. Inquiries made by Exner (1915) and

Davis (1929) showed that between 60% and 90% of college-trained men

and women remembered having practiced masturbation in their early

years. This fact alone should suffice to make one refrain from attaching

psychopathologic significance to the act itself. It is safe to say that

manipulation of the genitals often does not even have definite sexual

connotations in young children beyond the pleasurable sensations com-

mon to all other habitual manipulations of the body. Some investigators

have reversed this sequence and decided that thumb-sucking and nail

biting are masturbatory equivalents. The habit may, as it frequently does,

be a transitory type of sexual gratification. It becomes disturbing if it is

done in excess, is accompanied by too overpowering fantasies and, above

all, if unwarranted prophecies of illness and insanity upset a child's

security and outlook into the future (Malamud and Palmer, 1932).

Heterosexual behavior ranges all the way from attachments and

"crushes" and naive courting, "peeping," verbal annoyances, inspection

and manual exploration of the genitals of the opposite sex, exhibitionism,

and "petting" to sexual intercourse, assault and infantile prostitution.

Seduction by irresponsible adults, low standards of housing and intelli-

gence, loose sex behavior in the home and in the neighborhood are some

of the factors in the etiology of the serious forms of sexual misconduct,

7 86 PERSONALITY AND THE BEHAVIOR DISORDERS [25

to which instances of incest between siblings must be added as occur-

rences less rare than is usually believed.

Of homosexual practices among children, that of fellatio forms the

most frequent complaint brought to the attention of courts and clinics

and involving boys sometimes as young as six or seven years of age.

Most of them come from the lowest type of home standards.

The book by Moll (1909), though antiquated and often anecdotal, is

still the most comprehensive presentation of the "sex life of children" and

its anomalies.

ATTACK DISORDERS. Children are subject much more frequently than

adults to sudden and brief events of first magnitude, "attacks" or "spells,"

which for a few seconds, minutes or hours involve their total reactivity

and exclude them from their usual adaptations and participations.

Anxiety attacks have been mentioned before. Temper tantrums, breath-

holding spells and night terrors may also be viewed as attack disorders.

The classical picture of attack disorder, known commonly as epilepsy,

finds special consideration in this book in a chapter on "Seizure States"

by Lennox (see Chapter 31) and will therefore not be dealt with here.

Narcolepsy is a condition characterized by diurnal attacks of sleep

lasting about 10 or 15 minutes and initiated by a feeling of drowsiness

and irresistible fatigue. It is often associated with cataplexy, a sudden

loss of muscle tone precipitated by strong emotions. Though sometimes

a sequel of encephalitis or other brain disease, the "genuine" or "idio-

pathic" form is found in children in whom a cerebral disorder cannot

be demonstrated (Adie, 1926; Weech, 1926).

Fainting spells are known to occur in children under emotional stress,

especially at the sight of blood and in the excitements of graduation and

confirmation exercises. Those children show evidence of inadequate

balance of the autonomic nervous system (Stier, 1920).

MINOR PSYCHOSES. In adult psychiatry, a number of reaction sets

are comprised under the general heading of minor psychoses or psycho-

neuroses, to indicate that, though they represent marked disturbances of

personal functioning, they are less sweeping than the psychoses and the

patients manage to retain their contact with the environment. The usual

subdivisions are: Neurasthenia, psychasthenia, hysteria, hypochondri-

asis, and anxiety neurosis. Some of these headings can hardly be applied

to children ; this is particularly true of neurasthenia, which is about the

vaguest of all diagnostic concepts. Louttit (1936, p. 505) says rightly:

"Guthrie's (1909) statement, to the effect that children may be highly

neurasthenic from an early age, must be taken with caution. It is true

only if all varieties of behavior problems are subsumed under the term."

Psychasthenia refers to compulsive thinking and acting in a manner

which is recognized as irrational and serves no useful purpose. The

patient cannot shake off those obtrusive ideas in spite of his awareness

of their absurdity. The condition has also been designated as "obsessive-

25] BEHAVIOR DISORDERS IN CHILDHOOD 787

ruminative tension states." The ideational contents are usually divided

into obsessive thoughts, doubts and phobias. The commonest obsessions

and compulsions of children are fear of contamination with frequent hand

washing, fear of sickness, and the urge to do things in a certain way

only. The obsessive child is mostly overconscientious, shy, pedantic,

punctual, painstakingly addicted to the minutest orderliness, perfection-

istic in the evaluation of his own performances (Bender and Schilder,

1940).

Hypochondriasis is a chronic complaint habit. Imitation of observed

adult patterns, desire to retain privileges derived during a period of actual

illness, overwork with no recreational outlets, parental oversolicitude,

and medical mismanagement may all contribute to the development of

somatic complaints on a psychogenic basis. The feeling of sickness may

seriously interfere with the child's adaptations to the demands of every-

day life and create a state of chronic invalidism (Richards, 1923, 1941 ;

Levy, 1932; Kanner, 1937).

Much was written in former years about childhood hysteria. This is

largely due to the fact that the term was used indiscriminately to include

almost every type of behavior disorder. True hysterical disorders, ac-

cording to Adolf Meyer (unpublished lectures to students), "can be

shown to be substitutions which follow the type of more or less uncon-

scious self-suggestion, i.e., a suppression or repression of incompatible

experiences, with substitutive reactions, the connection of which tends to

be 'forgotten* and which, themselves, are often unheeded or accepted with

indifference and complacency, or with actual satisfaction, but great emo-

tional lability." If these criteria are applied, hysteria in children is rather

rare in this country at the present time. The most frequently observed

hysterical symptoms in children are "functional" blindness, deafness, and

paralysis of a limb.

MAJOR PSYCHOSES. The two prototypes of not demonstrably cere-

brogenic psychoses are schizophrenia and manic-depressive psychoses.

The latter of these is almost nonexistent before the age of puberty. A com-

prehensive review, with case illustrations, of the "functional" (not

definitely organic) psychoses in childhood was published by Kasanin

and Kaufman (1929).

Childhood schizophrenia, though also rare, has been diagnosed often

enough to create a considerable bibliography. The symptomatology in

older children approximates that of adult patients. In smaller children

the symptoms are fewer and simpler. The outstanding features are

seclusiveness, loss of interest in the surroundings, disturbance of affective

contact with people, emotional blunting, reversion to primitive forms of

behavior, negativism, mannerism, bizarre manner of thinking and speak-

ing, sensitivity to comment and criticism, and physical inactivity. The

schizophrenic development is sometimes preceded by grotesquely obses-

sive behavior (Potter, 1933; Bradley, 1941).

7 88 PERSONALITY AND THE BEHAVIOR DISORDERS [25

Therapeutic Principles

Even this brief and little more than enumerative outline undoubtedly

suffices to demonstrate the heterogeneity of children's behavior disorders.

Treatment, therefore, must vary with the individual child and his prob-

lems. There are surprisingly few organized presentations of the thera-

peutic principles involved. By far the best and most comprehensive is

contained in the book by Rogers (1939), who discusses the indications,

values, and results of treatment through dealing with the individual,

modification of his environment, and change of environment.

Treatment of behavior disorders may be defined as the sum total of

efforts made in behalf of the adjustment of a child who presents any form

of personality difficulty. This usually requires a number of well-defined

steps.

Realizing that we deal with a maladjusted person rather than merely

with a detached complaint or symptom, it is necessary to establish in the

child a condition of security, comfort, and well-being. Any existing

physical disorders should be remedied, regardless of whether or not they

are directly related to the problem of behavior. The child needs an

opportunity to discuss his problems frankly and without fear of ridicule

and criticism. The play methods, which we have previously described

from the point of view of their investigative advantages, offer at the same

time great curative possibilities, by giving vent ("release," Levy, 1939)

to the child's emotions, making it possible to relate himself to the

therapist (Allen, 1937) and to his life situation (Conn, 1939a), and

generally helping him to gain insight and giving him a chance to redirect

a hitherto misdirected pattern tendency.

Family collaboration is frequently an indispensable part of the treat-

ment. Not only will it be necessary to influence the parents' modes of

managing and training the child, but also to help them with their own

personal problems and attitudes which have caused or contributed to the

child's difficulties ("attitude therapy").

A considerable part of the treatment depends on community facilities.

Certain feebleminded, delinquent, epileptic and psychotic children require

institutional care. Certain dependent, neglected, or rejected children

need foster home care. The cooperation of the school becomes paramount

when grade readjustment of scholastically misplaced children is essential.

Often the child is helped when his specific problems and needs are ex-

plained to an understanding teacher. Much benefit can be derived from

working with recreational agencies. Above all, in many instances the

social workers of relief and case work agencies and clinics can render

inestimable and, at times, indispensable assistance.

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Chapter 26

DELINQUENT AND CRIMINAL PERSONALITIES

By LAWSON G. LOWREY, A.M., M.D.

IT is THE THESIS of this chapter that, despite extensive research and

many ingenious efforts to delimit them, there are no such entities as

"delinquent" or "criminal" personalities. To be sure, there are delin-

quents and criminals and, naturally, each has a personality, normal or

abnormal, but all attemps to establish a distinctive delinquent or criminal

type have eventually come to naught. It is necessary to review some of

the past efforts and examine them in the light of present-day knowledge

of personality, its evolution, driving forces and relationships to behavior,

whether the latter be social or unsocial.

With this specific orientation it is essential to define certain terms

freely used throughout. These definitions are not necessarily those em-

ployed by other writers, nor do they cover all possible variations of usage

and shades of meaning. They are, however, clinically acceptable and

adequately confine the discussion to reasonable and understandable limits.

Definitions

Behavior. In general terms, behavior is composed of the reactions

of an individual to situations which pile up tension or energy, discharged

by the reactions. All reactions of the organism, internal or external, to

all stimuli, internal or external, would therefore be included in the general

definition (Lowrey, 1926). This discussion, however, is limited to cer-

tain specific aspects of human behavior : the externalized, observable re-

sponses, reactions or activities of the individual. These aspects represent

the social behavior, i.e., comprise the various ways in which the indi-

vidual reacts to persons and things. More particularly, it is the socially

disturbing behavior which must be considered in this chapter.

Social behavior may be viewed in various ways. In moralistic terms,

it may be judged good or bad; in legal terms, as delinquent or law-

abiding ; in psychiatric terms, as normal or abnormal, etc. For reasons

to be presented, none of these dichotomies is adequate for understanding

behavior, more specifically, delinquent and criminal behavior.

Behavior may be satisfying to the individual in the sense that it meets

the inner need of a drive or tension for discharge. Or, the behavior may

fail to satisfy the drive or tension, in which case the organism continues

794

26] DELINQUENT AND CRIMINAL PERSONALITIES 795

in a state of partially or completely unrelieved tension. Behavior may

also be healthy or unhealthy, in accordance with its effects upon the

individual's physical and mental health. Finally, behavior may be socially

acceptable or socially unacceptable, in accordance with the mores or legal

concepts of the culture in which it occurs.

If behavior is satisfying, healthy, and socially acceptable, it obviously

presents no problem to individual or group. If it is satisfying to the in-

dividual, but socially unacceptable, the result is "problem" behavior,

delinquency or crime. Behavior which does not satisfy the individual's

needs, but is socially acceptable, would result in some form of inner dis-

turbance or illness ; while behavior not satisfying to the individual and

socially unacceptable would represent a form of neurotic or psychotic

delinquency.

Crime and Delinquency. Certain types of behavior are classified

as crimes, which are, for the most part, defined in penal codes. Defini-

tions usually include omissions and commissions of acts forbidden by

public law and punishable upon conviction. A crime, therefore, in the

abstract is an illegal act for which the perpetrator, if apprehended and

convicted, may be punished. Without going into technicalities, minor

offenses are arbitrarily defined as "misdemeanors" and major offenses

are called "felonies." The latter are more severely punished and involve

the loss of certain civil rights. While some types of offenses are described

as being such from their own nature or by natural law, for present pur-

poses the term crime will be used to refer to those offenses proscribed in

penal codes, with prescribed punishments.

Delinquency is a milder term referring to misdeeds, faults and mis-

demeanors. Technically, it seems to be applied only to the offenses of

juveniles under the age of sixteen or eighteen, and refers to any kind of

offense committed by children.

Both crime and delinquency are, in our culture, legal conceptions and,

as such, present variations in definition at various times and places. Both

imply a conspicuous deviation from the accepted standards of behavior,

as embodied in the laws governing the particular community and repre-

senting the social code of behavior. Codes may or may not be psycho-

logically well founded; when they are not, or a particular item is not,

widespread disregard ensues and the public attitude is one of condoning

the offender and his offense. Furthermore, many transgressions are

viewed more seriously by a family group than by the law, and vice versa.

In the present discussion the terms crime and criminal are not applied to

merely unethical or immoral, unprincipled or stupid conduct or persons,

but are used in the specific senses given.

Criminal and Delinquent. Technically, these terms are applied

only to those proven by plea or by conviction to be guilty of crime or

delinquency. The general tendency is to use the terms loosely to refer

chiefly to the repeated offender, or recidivist, but this is not entirely

correct. It is true that the recidivist group has been most closely studied

796 PERSONALITY AND THE BEHAVIOR DISORDERS [26

in the various efforts to establish a criminal type or delimit delinquent

personality. Furthermore, it is stated by Morris (1941) that 80% or

more of penitentiary prisoners have previous criminal records.

To some extent the differentiation of delinquent and criminal behavior

is dependent upon the standards of individuals or, more particularly,

families. Behavior acceptable to some families or social groups may be

regarded as serious transgression in others. Children reared in such

family or social groups are likely to share the views, with correspond-

ing freedom of action, or guilt and anxiety, in accordance with these

group standards. In general, however, the differentiation of criminal

land delinquent persons is dependent upon legal conviction of exhibiting

' behavior punishable by law.

It is recognized that this sharp delimitation to those who have actually

been adjudged delinquent does not take into account the large number of

individuals who are charged with delinquent behavior, or who actually

are delinquent over long periods of time without being apprehended.

This restriction is, however, both theoretically and practically essential

since, for the most part, adequate data are available only in the cases of

those whose delinquencies are acknowledged or proven. Further, and

tritely, incidental delinquency, witting or unwitting, is universal because

of the vast number of laws intended to govern social behavior. Studies

of various crime commissions have shown a wide disparity between the

number of crimes reported, the number of individuals arrested and

charged, those convicted and sentenced and the final carrying out of

sentence. Menninger (1938, p. 202), in discussing the problem of

criminality and possible differences in personality of those who are appre-

hended and those who are not, cites a survey of criminal justice in

Missouri in 1926 as showing only one offender actually punished for

every thousand crimes committed.

All in all, therefore, it seems desirable to discuss personality factors

only in the actually proven delinquent and criminal. The resulting con-

clusions may be open to criticism from the statistical standpoint, but no

other way is seen to delimit the population group to be studied.

Personality. Many and varied are the definitions which have been

proposed for this term, which is vaguely used in many senses. Aside

from the presentations in other chapters of this book, Allport (1937) has

contributed a discussion of some fifty definitions. For present purposes

the definition given in Webster's Dictionary is accepted as adequately

comprehensive, without being too specific or too exclusive : "Personality

implies complex being or character having distinctive and persistent

traits, among which reason, self-consciousness and self -activity are usually

reckoned as essential."

It seems probable that the stress on "total personality" in psychiatric

literature during the last few decades is dependent on the point that there

was a previous tendency to restrict the use of the word to particular

aspects of "distinctive personal character."

26] DELINQUENT AND CRIMINAL PERSONALITIES 797

Each person is an entity; as such, there is an independent physical

and mental being, a specific character, a series of attitudes, reactions and

behavior patterns. Many adjectives are used to describe various aspects

of personality, all of them referring to reactions of the individual to

situations which he encounters and to which he must respond. Many

"systems" of classification of normal and abnormal personality have

been devised, but none so far has stood the test of prolonged critical

examination. Several classifications of body types, with associated

temperaments, have been presented, now upon one bias, now upon

another. A recent one is that of Kretschmer (1926), describing four

anthropological types pyknic, asthenic, athletic, and dysplastic ; and two

major temperamental types cyclothymic and schizothymic (schizoid).

This system is apparently not of great practical significance in psy-

chiatry, judging by the small space devoted to it in recent textbooks

(one voluminous text does not even mention it) and the failure to in-

clude measurements derived from Kretschmer's scale in the section on

examination methods.

Actually, classifications are not especially important. The essential

point is to understand the mechanisms underlying the behavior of indi-

viduals and groups, especially, perhaps, of individuals in groups.

At any given point of study, personality is a complex derivative of

biological constitution and experiences interacting together. Its external

manifestations constitute the behavior we study. To a considerable extent

behavior and personality are socially determined, especially through

early experiences in the family, but neither behavior nor personality is

dependent solely on either social or cultural factors. With this point in

mind, the study of personality with reference to delinquent and criminal

behavior obviously must consider physical, intellectual, emotional, in-

stinctual (drives) and social factors, their interaction and integration

into a harmonious or unharmonious whole.

Abnormal Personality and Delinquency. The common thread in

the many approaches to the delimitation of a criminal type lies in the

obvious attempt to prove the criminal to be a variant from the normal,

a person set apart, different from the rest of the population. Also, and

quite specifically, it was evidently hoped that the criminal personality

might be recognized before it swung into action. Gross (1911) states

that the real criminal is different from the majority of people, adding

that the difference is great and essential, since a single characteristic

does not constitute a criminal (p. 411).

Ideas concerning crime, the criminal, and punishment have compli-

cated the picture, while themselves being complicated by concepts derived

from religion, philosophy and general group mores. Frequently, the

argument seems to run along the line that the individual committing a

delinquency (a socially disapproved act) must be abnormal, which is to

say, "he must be different from me." Michael and Wechsler (1940, pp.

20-24), after previously discussing complexities regarding what kinds

798 PERSONALITY AND THE BEHAVIOR DISORDERS [26

of behavior shall be made criminal by law, and how criminals shall be

punished, attribute the interest in objective study of the characteristics

of criminals primarily to the endeavor to discover the causes of crime,

with the ultimate end of elimination of causes, thus making possible the

control of crime. Noting that considerable material descriptive of ex-

amined individuals has been secured, they point out that much impor-

tance is attributed in contemporary criminal law to the individual char-

acteristics of offenders. They, as do most writers on the subject, note

that the factors, especially the external factors, to which delinquency may

be, and often is, attributed, also operate in the lives of non-delinquent

individuals. This point has been made especially clear by Healy and

Bronner (1936) through the study of 105 pairs of delinquent and non-

delinquent siblings, including eight pairs of twins.

While analysis of the personality of the delinquent cannot avoid the

inclusion of social factors, it should be emphasized that they are dis-

cussed only with reference to their dynamic influence as they are incor-

porated into and influence the evolution of personality. Causes of crime,

as such, are not under consideration, except as particular personality sets

enter into such causation. Evidence is cumulative that distortions of

personality play a large part in the exhibition of delinquent behavior ;

indeed, that certain conflicts, defects and mental mechanisms appear very

frequently in delinquents. In some instances it can be shown that specific

traits are present more frequently in delinquents, i.e., those delinquents

who have been studied, than in the general population. In other cases it

remains somewhat obscure as to why one individual reacts with delin-

quent behavior and another does not, although the mental mechanisms

seem to have similar origins and intensity.

In any case, the important point seems to be that careful, complete

study of the delinquent individual is essential to an understanding of his

personality, how it evolved, how it is related to the delinquency, and what

happens to the personality as a result of the delinquency.

Criminological Theories

Early Concepts. Even cursory survey reveals a wide variety of

explanations for criminal behavior, often offered with masses of sup-

porting data. In general, they are characterized by a comparatively

narrow attempt at one-to-one correlation, without taking into account

the complexity either of human personality or of the situations to which

the person must react. Of course, attempts at classifying people espe-

cially other people are as old as the human race. The fact that so many

theories have been offered to explain delinquent behavior proves the

enormous complexity of the problem.

POSSESSION BY THE DEVIL. Perhaps the oldest theory used to ex-

plain deviant behavior is that of "demoniacal possession," once a favorite

explanation also of mental disease. This notion is still deeply imbedded

in general viewpoints, as witness many phrases in everyday use, such as,

26] DELINQUENT AND CRIMINAL PERSONALITIES 799

"The devil is in him/* There are widely held beliefs in witchcraft,

"hexing/* the "evil eye/' and the like, which testify to the strength of

these ancient beliefs. Bromberg (1937, p. 44) cites an instance of witch

prosecution in New Jersey in 1936. (For a fairly comprehensive account

of these concepts, see especially pp. 43-66 of Bromberg's book.) A num-

ber of accounts of "hexing" have appeared in the newspapers during the

last few years. A more modern way of expressing much the same idea

is to speak of the "two sides of man," i.e., the good and the bad. Any

such concept of the essential basis for human behavior is, of course,

entirely too divorced from reality to be of service.

MORAL INSANITY AND MORAL IMBECILITY. A concept which re-

ceived great attention during the nineteenth century was that of "moral

insanity." The term was introduced by Prichard (1835), who defined

the condition as one apart from the "intellect or knowing and reasoning

faculties" and without "insane illusion or hallucination." The feelings,

temper, moral dispositions and natural impulses were subject to "morbid

perversion."

The condition itself had been called manie sans delire by Pinel. Rush

(1812) defined moral derangement as a state "when the will becomes

the involuntary vehicle of vicious actions, through the instrumentality of

the passions" (p. 262), and elsewhere emphasized the fact that there is

no "disease in the understanding." In 1810 he had limited "the morbid

operations of the will" to two acts, viz., murder and theft. In the later

work here cited, he added lying and drinking. The description of the

"lying disease in the will" is an excellent thumb-nail sketch of path-

ological lying as we know it today. In another chapter (p. 356) Rush

treats "derangement of the moral faculties" and cites three cases of

"total derangement." This he defines as innate and preternatural, and

probably due to "an original defective organization in those parts of the

body, which are occupied by the moral faculties of the mind." Although

Rush wrote extensively on the topic, Prichard's description seems to

have been the one most influential in stimulating the long controversy

regarding this concept. In this country most of the leading alienists

were involved on one side or the other, as were lawyers and sociologists.

Ray (1838), whose work on medical jurisprudence occupied a fore-

most position during much of the last century, classified moral insanity,

partial or general, under affective mania. The general type involved the

entire moral nature, while the partial was confined to one or a few of

the affective faculties, the remainder of the moral and intellectual con-

stitution being unimpaired. Crimes were committed whose motives were

equally inexplicable to the criminal and to others. Ray likened the

course of events to the working of a blind, instinctive impulse which

was irresistible. He laid especial stress on the propensity to destroy,

and attempted a differentiation between homicidal mania and criminal

homicide.

Most of the polemics which followed had to do, as might be expected,

8oo PERSONALITY AND THE BEHAVIOR DISORDERS [26

with problems of legal and moral responsibility. To many psychiatrists,

moral insanity was only a convenient term to excuse acts committed as a

result of ordinary desires or passions; or just another name for wicked-

ness or depravity.

Fink (1938), in his comprehensive and valuable discussion of this

concept (Ch. Ill, p. 48 ff.) to which the reader is referred for details,

points out that the trial of Giteau for the assassination of President

Garfield spelled the doom of the doctrine of moral insanity, but later

shows that similar concepts under other names have appeared.

Complicating the issue of moral insanity was the doctrine of heredity

and the concept of degeneration. Kiernan (1884) was among the first to

advocate the term "moral imbecility" to replace moral insanity, since the

condition was regarded as innate, and so hereditary, following Spitzka's

use of the term (Spitzka 1883, preface and p. 281). Again, however,

there was lack of clarity in definition. Tredgold (1915) gives a par-

ticularly good account of the "moral defective" (a term he preferred to

moral imbecile), in which he states (p. 313) that the moral defective

never developed the power of regulating personal conduct in the moral

and social sphere. He advanced the belief that defect of the moral sense

may occur without intellectual impairment, and distinguishes between

this type of person and the incorrigible criminal, stating that the latter

condition implies some degree of mental impairment (p. 321). He lists

three types of moral defectives: (1) the morally perverse, or habitual

criminal; (2) the facile type (with defective will); (3) the explosive

type. Most of his case illustrations are mental defectives with "moral"

difficulties added. This is a good example of the confusion regarding the

categories of moral insanity and moral imbecility, and explains many

of the apparent contradictions of theory and observation.

Tredgold (p. 321) says, "... my experience is that most persistent

criminals are the offspring of a decidedly neurotic or mentally abnormal

stock, and that they possess many characteristics identical with those

occurring in ordinary aments" (his term for the mentally defective or

feebleminded of all classes). He had previously pointed out that the

various "senses or sentiments" making up the mind differed in develop-

ment, partly due to special hereditary tendencies, and partly due to early

environmental influences. Especially, there must be sufficient will to

follow a course known to the individual to be right and ethical, and the

ability to inhibit antisocial and immoral impulses. He further noted that,

to a child growing up in an atmosphere of selfishness, vice and crime,

acts of thieving, lying and licentiousness would be meritorious.

Fernald (1908) expressed the view that every imbecile is a potential

criminal, needing only a particular environment and opportunity for the

expression of criminal tendencies. It was his definite opinion that there

were no moral imbeciles who were not true imbeciles. He also thought

the "instinctive criminal" of Lombroso (vide infra) might be a typical

adult imbecile who had had opportunity and experience in the com-

munity.

26] DELINQUENT AND CRIMINAL PERSONALITIES 801

In England, the category of moral imbecile was legally established

in the Mental Deficiency Act of 1913, in which moral imbeciles were

defined as "persons who from an early age display some permanent

mental defect coupled with strong vicious or criminal propensities on

which punishment has had little or no deterrent effect." The intent of

this passage seems clearly to be that of first establishing the diagnosis of

mental defect, which is primarily a matter of intellectual defect. Ac-

cordingly, this is not the same type of moral imbecility as that defined

by Prichard.

Various terms were proposed to apply to individuals of this type,

among them psychopathic personality (Ransom, 1896; Hitchcock, 1909,

et a/.) and constitutional inferiority (Wright, 1913). Wholey (1914)

stressed the inherent deficiency of the moral sense.

It remained for Healy (1915) to dispose of this debate rather neatly.

Pointing out that different authors discuss different things (p. 782 ff.)

and paying his respects to the problem of a "moral sense," he states that

there was no point on which he expected more positive data than the

moral imbecile, i.e., a person not subnormal or mentally diseased, yet

devoid of moral feeling. Not a single case was found. Cases brought

to him as moral imbeciles were mentally defective or otherwise dis-

ordered, or the victims of environment or mental conflict, but not devoid

of moral feeling. His final conclusion is, "... that probably all moral

imbeciles are primarily mentally abnormal" (p. 786).

Considerable space has been given to this discussion of "moral in-

sanity" and "moral imbecility" because, despite the confusion evident

among the disputants, these concepts have their place in determining

present-day views.

Much of the debate centered around the problem of free will. Thus

the various monomanias dipso-, pyro-, eroto-, klepto-, and homicidal

were described as having in common an intellectual recognition of the

wrongness of the act, which the individual would avoid if he could, but

volition was too weak to resist the impelling power. There was, until

Healy (1915) presented his case studies, a marked tendency merely to

group people according to their behavior, rather than to make careful,

individual case studies. The interplay of personality and environment

was glimpsed, but neither understood nor analyzed.

Even so able a student as Hall (1904, Vol. 1, p. 330) states that

"Moral insanity, which sometimes precedes and sometimes comes out at

puberty, is characterized by incapacity for education, distaste for family

life, marked peculiarities of character, extreme cleverness in certain

directions, bad sexuality and criminality. The more passionate and

instinctive men are, the more they resemble children in these respects

and the more egoistic they are."

ANTHROPOLOGICAL THEORIES. To explain deviation in social be-

havior, our predecessors (ca. 1850-1900) were sure there must be

anatomical or physiological differences between persons, in the organism

802 PERSONALITY AND THE BEHAVIOR DISORDERS [26

as a whole or in the nervous system. The criminal reacted differently

because he was organically different. In general, this is in line with the

expanding scientific thought of the times, when anatomical and patho-

logical laboratories were the chief centers of research.

Lombroso (1911) (see also Ferrerro, 1911) is universally credited

with the initiation of the concept of "criminal man" as a distinct type.

He insisted that the criminal was essentially atavistic, morphologically

a savage. Fink (1938) credits E. P. Fowler with the first American

publication in this field, an article in 1880 on the topic, "Are the brains

of criminals anatomical perversions ?" Atavism, reversion to type, in-

stinctive savagery and arrested development were favorite terms.

Arrested development referred particularly to the persistence of instincts

normal among savages and the semi-civilized, but regarded as evidence

of failure of development when occurring in our civilization. For ex-

ample, the inclination to assault or kill was explained as a persistence

of animal or subhuman ancestral traits. To many writers, the criminal

was an abnormal person to whom crime was a normal function. Further-

more, retrogression from generation to generation was claimed.

Many anatomical deviations were noted in all parts of the body, with

special reference to the head. Particular attention was paid to the

"stigmata of degeneration," some of which were the following: facial

asymmetry, tower skull, deformed palate (unsually high or pointed arch),

prognathism and receding lower jaw, scanty beard, low growing head

hair and low forehead, meeting eyebrows, deformities of dental arches

and teeth, coarse features, high cheek bones, very broad or very narrow

face. The ears were particularly studied for asymmetries, protrusion,

adherent lobules, anomalies in conformation and the Darwinian tubercle.

Through such studies, a concept of the criminal as a degenerate, or

devoluting type, was evolved and a considerable literature developed.

Talbot (1898) set up a classification of degeneracy. "Ethical degen-

eracy" included crime, prostitution and sexual degeneracy, moral in-

sanity and inebriety. Intellectual degeneracy comprised the insanities,

neuroses and epilepsy ; sensory degeneracy, deaf -mutism, congenital color

blindness, etc. ; nutritive degeneracy, goitre, cancer, gout, etc. ; and local

reversionary tendencies in the various organs were described. Lydston

(1904) attributed all degeneracy to a neuropathic constitution, which

might not be obvious, but latent, until the neuropsychic degeneration is

revealed by inebriety or criminal acts.

The theory of degeneration brought crime, insanity, mental deficiency

and pauperism into a sequence of cause and effect, not accidents or due

to "satanic interference." Reviewing the period, it now seems that

concepts of brain and nervous system, physical constitution, intelligence

and will, were quite thoroughly mixed up. A frequent sequence was

that defective conduct was rooted in defective brain action, dependent in

turn on defective brain structure which was most probably usually in-

herited. Also, criminality was either hereditary or environmental in

origin ; very few considered the possibility of interplay.

26] DELINQUENT AND CRIMINAL PERSONALITIES 803

The present status of criminal anthropology has been well sum-

marized by Hrdlicka (1939), who says there are recognizable anthro-

pometric differences between the averages of the main criminal classes,

but they are not sufficiently characteristic, nor are they universal. Noting

that crime is not an organic entity, but a social phenomenon, he con-

cludes that anthropometry and physical examination cannot aid in the

recognition of the potential criminal.

For about thirty years, there was much interest in the question of a

specific type of criminal brain. Benedikt (1881) showed, in nineteen

brains of criminals, a simplified type of architecture (confluent fissures).

Apparently up to the time of Benedikt's report these anomalies of gyra-

tion had been only infrequently noted. Following his report, however,

similar conditions were described in brains from many individuals with

a wide variety of types of disturbance. The idea of a specific type of

brain configuration, never well accepted, was finally abandoned. That

gyral interruption or sulcal confluence is common in certain types of

disorders and may have a bearing on organization and functioning of the

nervous system, is shown by my own observations in 100 brains, in

which 44% of 63 cases of organic and toxic psychoses revealed these

anomalies, while practically 95% of 37 cases of functional or endogenous

disorders presented such findings (1920). While emphasis has shifted

to the social and psychological aspects of crime and the criminal, it

remains true that nothing has been produced to show any relationship

between the brain of the criminal and his acts or habits, aside from those

pathological manifestations which are related to certain types of mental

disorders which, of course, may be complicated by crime.

Much the same comments could be made regarding the findings of

craniology. Fink (1938) credits August Drahms (1900) and Frances

A. Kellor (1901) with producing the first two works on the American

criminal. Significantly, neither was able to demonstrate a type of cranium

peculiar to the criminal.

To sum up, it may be said that no distinctive physical type of criminal

has been proven to exist. There are observations indicating certain

trends toward inferior constitutional endowment, but these are not spe-

cific for the criminal.

HEREDITY. The theories of degeneration, of moral insanity and

moral imbecility, and of the criminal anthropological type, were all com-

plicated by ideas of hereditary transmission. While the doctrine of

heredity was perhaps particularly stressed in relation to degeneration,

it was argued pro and con with reference to all the other theories, and

mental disease and mental defect as well.

Of the great mass of literature which accumulated, only three works

will be cited here. The first was Dugdale's (1877) study of a family he

called the Jukes. This study has often been used in support of the thesis

of hereditary transmission of criminal characteristics. Yet the author

himself was careful to point out that not only hereditary blood lines, but

804 PERSONALITY AND THE BEHAVIOR DISORDERS [26

similar environment, were involved. It was his view that hereditary

characteristics produce a corresponding environment and so tend to per-

petuate the characteristics. He regarded heredity as an organized result

of the environment which produces habits which tend to become heredi-

tary. While this is not acceptable doctrine today, his statements to the

effect that capacities are limited by heredity, and the use to which they

are put is governed by environmental influences, is thoroughly in accord

with the most modern views.

The second study is that of Goddard (1912) on the Kallikak family.

Here again, a numerous family was traced through many generations.

Goddard concluded that criminals are made and not born. But in this

and other works, he also stressed the importance of feeblemindedness in

the production of criminality, and further concluded that feebleminded-

ness was inherited. Hence there might appear to be some equivocation

in this argument. It was his opinion that Lombroso's criminal types may

have been feebleminded individuals who became criminal because of

environmental circumstances.

Finally, Spaulding and Healy (1914), in a study of a thousand young

recidivists, found no evidence of direct inheritance of criminality, but did

find familial incidence of insanity, epilepsy and feeblemindedness which

could have been of indirect importance.

It seems justifiable to conclude that, in so far as heredity is concerned,

even the proponents of the theory have shown only that certain funda-

mental defect states are transmitted in familial lines, and that these must

be combined with environmental influences to result in criminality.

CONCLUSIONS. It is clear that all the efforts described in this section

were concerned with (a) the delimitation of a criminal type or types,

and (b) the causes of criminal behavior. The orientation was chiefly in

physical and neurological terms, with only here and there reference to

sociological and psychological factors. Despite an apparent abstractness,

these studies were of importance because of the gradually increasing

emphasis on the study of the individual, rather than of a type or of the

crime. This has permitted the emergence of our present concepts of the

personality difficulties of delinquents. Furthermore, the failure of these

efforts led to a definite shift in the search for causes from a somatic to

a psychological orientation. With the increased study of psychological

factors, and the perfection of diagnostic techniques, there came an in-

creasing emphasis on social or cultural components in human behavior.

Both problems in behavior and in personality must be studied in relation

to environmental influences, as well as in terms of psychobiological con-

stitution. Finally, the most significant finding of twentieth century

psychiatry has been the demonstration of the continuity of mental life,

and, as a corollary, the far-reaching influence of past experience, espe-

cially early experience, in determining personality and behavior patterns.

Actually, it is to the dynamics of mental life that we must turn

for the explanations of behavior. As Healy (1915, ft 23) put it,

26] DELINQUENT AND CRIMINAL PERSONALITIES 805

we deal with the motives and driving forces of human conduct, a product

of mental life. Hence the problems are essentially those of individual

and differential psychology. To this we would add the importance of

cultural factors in producing the psychology of the individual. Signifi-

cantly, we shall not find a doctrine of monocausation tenable. Instead,

especially in the field of behavior, multiple causation is clearly demon-

strable. This is one of the most significant contributions of the child

guidance work of the past twenty years.

Mental Disorders

Leaving to one side such uninformed judgments as those proclaiming

that all criminals are insane or feebleminded, or that criminality is a

diseased condition of the human character, or that the criminal is a

psychopath whose dominant passion is to commit a crime, it has been

found that some of those who commit crimes are mentally disordered.

The relationship of the major types of mental disorder the psychoses,

mental deficiency, epilepsy, the neuroses, and psychopathic personality

are separately discussed.

Psychoses. There is considerable discrepancy in figures on the rela-

tive incidence of the psychoses among criminals. In most states, provi-

sion is made for special institutional care of the criminal insane who are

committed under special legal provisions. In case of recovery from the

psychosis, offenders may frequently be tried for the original offense if

that was not adjudicated at the time of the commitment.

In ordinary prisons, the proportion of psychoses, either present on

admission or developing during incarceration, seems to vary considerably.

Variations in diagnostic standards, in methods of keeping statistics, and

in ideas regarding punishment, probably contribute to the apparent

variations. From 5% to 15% of prisoners have been reported to be

psychotic.

Reporting on 9,958 cases (the largest series found in the literature)

examined at the New York Court of General Sessions, after conviction

or a plea of guilty, Bromberg and Thompson (1937) presented the fol-

lowing findings :

Psychoses 1.5%

Mental deficiency 2.4

Psychopathic personality 6.9

Psychneuroses 6.9 (of 7,100 cases)

Average or normal 82.0

While the rate of psychoses is considerably higher than in the gen-

eral population, it is clear that the presence of a psychosis does not

account for any substantial proportion of criminal activity. These figures

seem particularly important because they are based on complete exam-

ination pf all convicted adult offenders and so comprise a random sample

806 PERSONALITY AND THE BEHAVIOR DISORDERS [26

large enough to be representative. The standards of psychiatric work

in this court clinic are of the best.

By contrast, Bernard Glueck (1918) studied 608 admissions to Sing

Sing Prison and reported 12% with mental disease; 28% mental defi-

ciency ; 19% psychopathic personality ; or more than half of the cases

with some definite type of mental abnormality.

Another index of the incidence of psychoses in relation to criminal

activity might conceivably be found in the number of cases becoming

psychotic in prison. While such figures are extremely misleading, it

may be noted that, of a total of about 12,000 inmates (average daily

census), 156 were transferred from correctional institutions to state

hospitals in New York in 1939 (Commission of Correction Annual

Report, 1940).

These later reports are not, of course, based on any such concep-

tions of "moral insanity" as have been previously discussed. Their

validity might be questioned with respect to general social and legal

attitudes toward "the criminal" and the need for, and effects of, punish-

ment. Nevertheless, according to the best modern studies, psychoses are

not overwhelmingly important factors in delinquency. On theoretical

grounds alone this should be expected, since the types of symptom

formation in the psychoses and in delinquency are, on the whole, quite

different.

Mental Deficiency. Some earlier views respecting the relationships

of mental deficiency to crime have already been presented. Modern

studies may be said to date from the introduction of the Binet-Simon test

in this country in 1910 by Goddard. Reports multiplied from all parts

of the country, dealing with all types of delinquents (as well as socially

and educationally defective). Most extraordinary were the proportions

of diagnoses of feeblemindedness reported. Figures of 25% to 90%,

and in some small series of cases, 100%, were reported (see Goddard,

1910, 1914). It is easy to understand why these extraordinarily high

figures were received with great skepticism by the majority of psy-

chiatrists. These studies are not listed in detail, because it soon became

clear that much depended on methods of scoring and interpretation. At

first, feeblemindedness was estimated in terms of mental age and num-

ber of years of retardation; then, in certain tests, by the number of

points; later still, in terms of intelligence quotient (see, for example,

Haines, 1916). The most reliable results were eventually found to be

through the use of batteries of tests. Especially the Army experience

during 1917 and 1918 showed the need for care in standardization and,

at the same time, gave an enormous random sample of males of con-

siderable age range and varied socio-economic, cultural and racial back-

grounds.

The study of the intelligence levels of criminals by Tulchin (1939)

is the most comprehensive yet to appear and gives the most complete

answer obtainable to the question of the relationship between feeble-

26] DELINQUENT AND CRIMINAL PERSONALITIES 807

mindedness and criminal behavior. The data include the results of a

1920 survey of all inmates in Illinois penal and correctional institutions,

followed by routine psychometric testing of all admissions through 1927,

comprising 10,413 prisoners. The standard procedure was to use the

Army group intelligence tests, Alpha or Beta as indicated, followed by

individual testing of all those with rating below C (Alpha) or 45

points (Beta), except that, in the latter part of the study, use of the

Beta test was eliminated, and all who would have been chosen for this

test were given individual tests instead. With the exception of two

groups, totaling 517, who made low Alpha scores and left the institution

before individual examinations could be administered, all diagnoses of

feeblemindedness were based on individual tests. The data were subjected

to detailed analysis and comparison with the test results reported for the

Illinois Army draft. The major conclusions may be briefly summarized.

There are a number of important differences between the populations

of the State Penitentiary and the State Reformatory, and some differ-

ences are shown between the 1920 survey results and the 1920-1927

study. But, so far as intelligence is concerned, the outstanding point is

that the percentages of inferior, average, and superior men in the prison

population are extremely similar to those for the Illinois Army draft

(see Tulchin, pp. 11-14). In point of fact, tests of nearly 5,000 men

in the Reformatory showed a higher proportion of superior test results,

and a smaller proportion of inferior, than did the Army draft. The

entire institution population revealed 20.4% inferior, 67.6% average,

and 11.9% superior results, by comparison with 25.9% inferior, 63.5%

average, and 10.6% superior for the Army draft.

With specific reference to the occurrence of inferior intelligence

(mental ages below 10.9) the following percentages were found: Army

draft, 25.9; 1920 survey of the penitentiaries, 24.4; seven-year admis-

sions to the State Penitentiary, 23.4 ; similar study at the Reformatory,

15.0.

The difference between the several groups is to be explained, accord-

ing to the report, by differences in proportion of native-born whites,

foreign-born, and Negroes in the Reformatory, the Penitentiary, and in

the Army draft sample. The latter compares much more closely with the

penitentiary population in average age and in distributions by nativity

and race than it does with the reformatory group. Marked variations

were found in intelligence distributions on comparing the several nativity

and racial groups, arid these must be taken into account when comparing

intelligence distributions. Cultural and educational factors were found

to be definitely important in relation to test scores.

It is of great significance, however, that for all nativity and racial

groups, test results from the institution population approximate the dis-

tribution for the Army draft. In most instances where there is dis-

crepancy, it is that the reformatory group shows a lower proportion of

inferior test scores and a higher proportion of superior scores.

The final conclusion, for our present purposes, is that a most adequate

8o8 PERSONALITY AND THE BEHAVIOR DISORDERS [26

study has failed to produce evidence of any significant disproportion of

test scores for male delinquents when compared with scores earned on

the same tests by a draft group from the same areas. Some nativity and

race groups in both series show quite high percentages of inferior ratings.

As pointed out in the report (pp. 33-35), it would be absurd to label

these large groups feebleminded. The only direct comparison made for

those of lowest rating (E, below MA 9-6, or IQ 60) is for the native-

born whites, where the percentage for Army and the penal group is

approximately the same, 3.5% to 4.0%.

Some relationship is found between the level of intelligence test scores

and type of crime, in that the highest median scores were made by the

men committed for fraud ; the lowest by those committed for sex crimes.

Individuals of all grades of intelligence were found in the six crime

groups listed (fraud, robbery, larceny, burglary, murder, and sex crimes,

in about that order for intelligence levels).

How shall we explain the high proportions of mental defect reported

in the early studies, up to 100% in some instances, and the much lower

proportion found in this Illinois study, with a curve of distribution prac-

tically identical with the Illinois Army draft? It has been mentioned

that there were wide variations in types of tests used and, more espe-

cially, in the interpretations placed on the findings. Besides this impor-

tant point, it seems probable that many delinquent or potentially delin-

quent younger feebleminded were committed to training schools for

mental defectives, with the development of greater interest in their train-

ing and the provision of more facilities. Or, they may have been put

under some form of prolonged social supervision, operating to reduce

the incidence of delinquency among the defective. Tulchin brought out

the fact that recidivists have somewhat higher median scores, chiefly

because of a reduction in the percentage of inferior scores (pp. 42-49).

He suggests several possible explanations, among them longer sentences

for the defective, more rigid supervision on parole, and commitment to

training schools.

The conclusions drawn from the Illinois study regarding the inci-

dence of mental defect among delinquents are, to a considerable degree,

supported by the findings of Bromberg and Thompson (1937). Among

4,396 convicted prisoners, 2.2% were found to be feebleminded, and an

additional 26.3% inferior, by contrast with the finding of 7.1% feeble-

minded and 17% inferior among 94,000 white draftees used as a con-

trol. The major difference in their findings from those in Illinois was

that only 2.5% of their prisoners were superior in intelligence rating.

Feeblemindedness, then, is not the universal factor in delinquency it

was once thought to be (see Lowrey, 1928a). Even inferior intelli-

gence, broadly conceived, cannot be considered to be an outstanding

feature of the personality of delinquents, since the incidence of inferiority

is, in general, so nearly the same as with the Army draft.

These studies of the incidence of the psychoses and mental defect

among delinquents deal only with convicted adult and adolescent

26] DELINQUENT AND CRIMINAL PERSONALITIES 809

offenders, and so may be criticized. However, these are the known

offenders, with known, punishable offenses. The important point is that

this most deviant behavior group proves to be, so far as we have norms

with which to compare them, a reasonably fair cross-section of the

population.

Epilepsy. This is one of the rarer forms of mental disorder, but an

especially important one in relation to delinquency because of the bizarre

features often found. These include the amnesia (often mistaken for

malingering) and the extraordinary brutality of many of the crimes in

which epilepsy is regarded as the important factor in causation. Cases

of epilepsy are, fortunately, rare, and so are their delinquencies. In many

reports consulted, epilepsy was not mentioned. Foxe (1938), noting

that epilepsy was rare in his experience with prisoners, suggested that

epilepsy may be a form of criminal behavior lived out on oneself.

Neuroses. Fully developed neuroses are relatively rare as causative

factors in delinquency. Bromberg and Thompson (1937) reported an

incidence of 6.9% among 7,100 prisoners examined. In general, hysteria

is the neurosis most commonly involved, an especial complication being

the amnesia frequently found with respect to the delinquency.

This low incidence of neuroses in the causation of delinquent behavior

is to be expected, since neurotic mechanisms tend to appear in the form

of symptoms of disturbed function. Medical experience indicates a much

higher proportion of neuroses in the nondelinquent population. Minor

degrees of disturbance in social relationship are common symptoms in

neurotics, in line with the disturbances of physiological functions.

Recently psychoanalytic studies of delinquents have appeared with

greater frequency, and these indicate that delinquency more frequently

represents the working out of neurotic conflicts than had been believed

(see especially Alexander and Healy, 1935; Lippman, 1937; Aichhorn,

1935; and Menninger, 1938). Of particular importance are (1) the

unconscious need to be punished, (2) displaced aggression, and (3)

various compulsions based on unconscious needs, many of which, in

individual cases, may be shown to have a sequential relationship to the

other two. Most frequently the compulsions are related to suppressed

aggression, often directed against the self. In other words, the crimes

of the neurotic are symbolic, as are other symptoms.

So far as present reports are concerned, there is more evidence that

repressed hostile impulses lead to guilt formation and neurosis than the

reverse. Gutheil (194 la, b) has given an outline of the method of re-

pression and conversion of the primitive hostile impulses into various

neurotic symptoms. He presents the point that the neurosis acts as an

immobilizer of criminal trends as part of the constant conflict between

hostile impulses and the need, both psychological and social, to be part

of a group.

After all, only two ways are open to a psychological impulse. One is

8io PERSONALITY AND THE BEHAVIOR DISORDERS [26

to act on it, thus discharging the energy. The other is to suppress it,

which leads to anxiety and symptom formation.

Psychopathic Personality. This diagnostic term is, in at least one

sense, a lineal descendant of the "moral insanity" discussed in a previous

section. Conditions included under this diagnosis have been variously

named, described, grouped, and interpreted. For discussion of the psy-

chopathic states from several points of view, including relationship to

delinquency, Preu's chapter in this book (Chapter 30), Kraepelin

(1915), Henderson (1939), Cleckley (1941), Caldwell (1941), Karp-

man (1933, 1940), Healy (1915, p. 575 ff.), and Partridge (1930) may

be consulted. A particularly concise discussion may be found in Noyes

(1934), while an excellent survey of the literature will be found in

Maughs (1941).

For present purposes, it may be noted that a variety of terms have

been used to describe types of personality and behavior regarded as

aberrant and socially or personally destructive. Psychopathic person-

ality, constitutional psychopathic inferiority, constitutional inferiority,

constitutional psychopathic state, and psychic constitutional inferiority,

are the most common. Latterly, there has been a trend toward calling

similar cases "neurotic character" (e.g., Bartemeier, 1931 ; Alexander

and Staub, 1931; Alexander and Healy, 1935; Lippman, 1937).

Inclusions of cases in this group have been of two major types: (1)

those showing personality characteristics which, if exaggerated or

developed by the addition of certain other symptoms, would represent

a psychosis; and (2) those showing deviations from generally accepted,

though vaguely defined, norms of personality integration, together with

antisocial behavior, commonly as a repetitive pattern. In the main, it is

the latter type which is of present concern. Interpretations have also

followed two main lines: (1) that of constitutional, innate, hereditary

factors ; and (2) disturbances in personality development and integration,

primarily dependent upon the nature of early experience, especially

emotional relationships.

Questions concerning types of cases to be included, factors in causa-

tion and interpretation have recently again come to the fore and this

interest is reflected in the rising tide of literature. It is worthy of note

that some psychiatrists deny the existence of the condition [see, for

example, the discussions by Brill and Menninger of Sprague's (1941)

paper]. To others, all criminals would seem to be psychopathic.

Probably because of the uncertainties of diagnostic standards in these

borderline cases, there is considerable variation in reported incidence.

Although recognizably ill and repeatedly failing to profit by punitive

experience, these cases are held fully responsible in legal procedure.

In the early '20's in the Psychopathic Laboratory of the Chicago

Criminal Courts, the great majority of the cases studied were called

"dementia praecox," in addition to any other conditions which might

have been found, and poverty of affect was regarded as the most impor-

26] DELINQUENT AND CRIMINAL PERSONALITIES 811

tant single point in the makeup of the criminal (see reports issued in

those years). Anderson (1914, 1915) had already noted that the con-

stitutional psychopath one not feebleminded, not psychotic, but with

such personality disorganization that he could not adjust to the social

environment was as frequent as the feebleminded in his court clinic.

He differentiated between the mental defective (the defective delinquent,

for whom special provision has been made in some States, notably New

York), the psychopaths, and the "mental delinquent" with an acquired,

reformable delinquency.

Glueck (1918), reporting 19% of psychopaths among 608 admis-

sions to Sing Sing Prison, showed, among other things, that the inci-

dence of recidivism in this group was high; that various types of

unstable, more or less antisocial behavior were common ; that school and

work careers were usually irregular and inefficient ; that marked devia-

tions from average behavior were found in childhood histories. Many

of the latter disturbances were in the nature of rebellion against all types

of authority, restrictions, etc.

Healy (1915) reported that "mental abnormalities and peculiarities"

appeared as a main causative factor in 455 of 823 cases. There were 20

cases designated as "constitutional inferiority, including marked neuras-

thenic and psychopathic types" (pp. 130-132). This, by contrast with

the 58 cases in which "mental conflict" was given as a major causative

factor.

Healy and Bronner (1926, pp. 152, 273) reported 2.8% of psycho-

pathic personality among 2,000 juvenile offenders, and 2.0% of con-

stitutional inferiority. Among 675 cases used for a follow-up study,

there were 14% of psychopaths, 16% of whom were also classed as

feebleminded (p. 274).

In their latest report (1939) these authors dealt with 400 cases fol-

lowed up five to eight years after study. Of these, 207 had presented

"personality and behavior problems"; while 35 were classed as having

"definitely abnormal personality." Of these, 14 were called psycho-

pathic personality, 9 constitutional inferior, and 5 unclassified. Another

9 were called "probably abnormal personality." At most, then, the

psychopaths constitute only 3.0% to 5.0% of juvenile delinquents,

according to these figures.

For adults, Bromberg and Thompson (1937) reported, as previ-

ously noted, 6.9% of psychopathic personality among almost 10,000 cases

examined. These included the schizoid, paranoid, cyclothymic, sexual,

constitutional inferiority, drug addiction, and the explosive (epileptoid).

A survey of their "normal or average" types shows at least 22.2% which

might be included in the psychopathic group, at least according to the

brief descriptive notes [emotionally unstable, 11.3%; egocentric (char-

acter defect) 5.3%; dull, adynamic, 2.5%; adult immature, 3.1%]. In

any case, only 17.2% were recorded as "balanced or adjusted," with

another 3.6% of "low cultural level" and 7.2% showing characteristics

of the psychology of adolescence ; or, perhaps at most, some 27% to 30%

812 PERSONALITY AND THE BEHAVIOR DISORDERS [26

of reasonably average or normal types. (In a personal communication,

Bromberg reports that these cases are being restudied, with special ref-

erence to the problem of the neurotic character. The figures are, there-

fore, subject to other interpretations.)

It is accordingly necessary to leave in abeyance the question of the

quantitative occurrence of psychopathy among delinquents. It may be

noted that surveys of county jails, houses of refuge, etc., where so many

recidivist misdemeanants are sent for short sentences, have revealed

much higher percentages of psychopaths than is shown in the studies

here cited. Experience in correctional institutions indicates some 20%

to 25% of psychopathic personality among inmates. This may be related

to a variety of factors the repetitive behavior pattern, with high inci-

dence of recidivism, the characteristic, egocentric failure of the psycho-

path to profit by experience, the rather obvious social disabilities, etc. It

should also be noted that not all psychopathic personalities are delinquent

in the strict sense used here; in many instances their inability to adjust

socially is worked out in other ways. The diagnosis of psychopathic

personality is never to be based on the occurrence of delinquent behavior,

or even on its repetitiveness, but upon rather specific personality pic-

tures.

Summary. While the most recent figures available show consid-

erable variation, it would appear that all personality disorders of the

most marked types (psychoses, mental defect, neuroses, epilepsy and

psychopathic personality), judged by the best modern studies, account

for only about one-fifth to at most one-third of the cases of delinquency,

at least for the more serious types. There are some differences according

to age. Thus, there are very few psychotics among children, among

whom the percentage of mental deficiency is higher than among adult

offenders. Healy (1915) reported 11% of mental defectives among 832

juvenile delinquents, and juvenile court reports commonly show a skew

of the curve of intelligence distribution to the left. Neuroses are con-

siderably more frequent than psychoses, yet not extremely numerous.

Most numerous of all, and the most complex to diagnose and treat, are

the psychopathic personalities or character defects, which appear to be

more numerous in adults than in children. It is clear, however, that

there is no such entity as a "criminal type/' either physical or mental.

On the contrary, it would appear that there are complex psychological

patterns involved, and that we must turn to a consideration of the indi-

vidual delinquent and particular mental mechanisms.

The Delinquent Individual

Personality Types. From the preceding discussions it appears that

the delinquent is not especially different from the general population so

far as gross personality disturbances are concerned. The neuroses are

apparently more frequent ih the general population; mental deficiency

appears to occur with about the same frequency among delinquents and

26] DELINQUENT AND CRIMINAL PERSONALITIES 813

comparable sections of the general population; psycnoses and psycho-

pathic states are apparently more frequent among delinquents.

To function normally in terms of social behavior requires not only

freedom from mental disorder of all types, but also adequate physical

and mental equipment for a well-balanced personality. As part of this,

inhibiting powers are necessary. Mental activity is necessarily directly

antecedent to criminal behavior, as to any other. Inhibitory powers are

a direct function of the super-ego, in so far as they pertain to social

behavior. One of the characteristics of an inadequate personality is

weakness of inhibitory activity, a sign of failure of development, or, in

the broad sense, immaturity. In such cases, faulty ego-ideals and im-

perfect transformation of the original, normal, egocentricity are also

evident. These and other deviations in personality formation occur and

profoundly influence behavior, without necessarily resulting in grossly

abnormal personality.

Healy (1941), after more than 30 years study of the problem, con-

cludes that both biological and social factors are components in the pro-

duction of delinquency and criminality. This point, which the child guid-

ance work of the past twenty years has emphasized from the beginning,

is most important in considering the delinquent individual. Healy fur-

ther concludes from the researches of his group, that there are two types

of abnormal personalities who became delinquent and criminal. One type

proves to be inadequate in personality makeup, and he calls them consti-

tutionally inferior personalities. The other group shows abnormally ego-

centric and unstable personalities. These conclusions may be viewed in

the light of the finding by Healy and Bronner (1936) that 23.5% of 153

cases were definitely abnormal in personality, while inclusion of those

"probably" and "possibly" abnormal would raise the figure to 30%.

Bromberg and Thompson (1937) list 18 different groupings among

the 82% of "average or normal" types reported in their study of court

cases, based on particular traits which predominated in the total person-

ality makeup. They finally emerge with 17% to 21% of "balanced or ad-

justed" among their cases. Types occurring with considerable frequency

in their groupings are: aggressive, 7.3% ; emotionally unstable, 11.3% ;

egocentric (unmodified ego as character defect), 5.3% ; shiftless, 8.4% ;

weak and submissive (suggestible), 5.2%. They also list an "unethical"

group (2.5%) who pursue carefully planned criminal careers. To an-

other 1.0%, called the primitive, is ascribed simple, instinctive behavior

of a delinquent nature.

It would appear, therefore, that there are dominant traits, or factors in

causation, which may be important in individual cases, but not to the

extent that they may be regarded as personality types. Some sociologists,

notably Reckless (1940), believe that the search for causative factors is

a hopeless task, but this view seems extreme and unjustified by the data

at hand. There are many environmental factors which enter into the pro-

duction of delinquent behavior, but they in turn must be transmuted

in the subtle alchemy of personality integration. Certain mechanisms

8i 4 PERSONALITY AND THE BEHAVIOR DISORDERS [26

within the personality have been shown to be especially important and

frequent among delinquents. No attempt is here made to assign any

statistical frequency, or to indicate the rich variations of combinations

which are encountered.

Fundamental Mechanisms.

INDIVIDUAL DIFFERENCES, AND THE CONFLICT OVER DIFFERENCE.

An outstanding characteristic of contemporary life is its competitiveness

in a wide variety of fields, affecting many phases of mental life. The

effectiveness of the individual in many of these competitive fields is often

directly related to the problem of competence (general or special dis-

abilities or abilities). Frequently, however, it is not so much a question

of actual competence as it is the individual's feelings about himself, the

well-known inferiority complex, or, as it has been called for well-defined

reasons, the conflict over difference (Lowrey, 1928). Healy and Bronner

(1936) report conscious feelings of inferiority in one-third of their

delinquency cases (p. 46), and later noted (p. 49) that there were marked

feelings of inadequacy or inferiority in some situations or activities in

sixty-one of 143 cases, or 43%. In my own experience with young

offenders, this conflict as a precursor of socially disturbing behavior is

very common, occurring with especial frequency in cases of stealing,

truancy and running away, extremely aggressive, attention-compelling

behavior (as a compensatory mechanism) and where submissive, with-

drawn behavior is related to the delinquency, often as a part of so-called

increased suggestibility.

The conflict may arise with respect to any attribute of the individual

physical abilities and appearance, intellectual abilities, emotional and

behavior characteristics, economic and social status of the family or self,

race, religion, vocation (especially where there is a difference between

vocational interests and the vocation actually engaged in), etc. The

mechanism of the conflict is related to the ego-ideals, real or imagined,

of the individual and the group or groups in which he wishes to be

accepted and valued and, perhaps, be a leader. Anything at all which

happens in group relationships to indicate that the individual is not

acceptable, or is actually regarded with hostility, may activate the

mechanism. Often nicknames are especially expressive of the under-

lying emotional attitudes of a particular group, since they so frequently

emphasize rejection of some reality factor which the individual cannot

control. Color of hair, race and associated cultural patterns, and physi-

cal build are good examples of such reality situations which may be

painfully impressed upon the developing ego. The manners and customs

of the family group may contrast sharply with those of families in the

neighborhood, with resulting conflict, as, for example, in the case of

children whose foreign-born parents attempt to maintain their foreign

patterns of personal and family life in the face of the quite different

patterns of their neighbors.

There are several elements involved in the conflict. One is the drive

26] DELINQUENT AND CRIMINAL PERSONALITIES 815

for self-maximation, which involves (a) the realization of a sense of

personal adequacy to meet the everyday demands made upon the indi-

vidual, and (b) the realization of security in the group, as measured by

the real or imagined expressions of the group. Under ordinary circum-

stances, an individual is not able to develop a complete feeling of personal

adequacy, or complete group security. But, for the average situation,

there are compensating satisfactions to be gained in some way, which

offset with reasonable completeness the frustrations.

In addition to this ego drive, there is also the drive for group con-

formity, which has libidinal as well as ego components. This is worked

out in relation to many groups, two of especial importance being the

family and the own age group of companions. Frequently the standards

of these two groups are in conflict. Particularly in the later adolescent

years, when delinquency rates are especially high, the need for own age

group conformity is unusually great. This is complicated by a variety of

factors having to do with the establishment of independence from the

home, resolution of the Oedipus situation, heterosexual adaptation and

achievement of vocational and societal status.

That this is a period of great conflict between instinctual drives, and

between certain drives and inhibiting factors, derived in part from within

and in part from without, is clearly indicated by the high incidence of

delinquency. Healy and Alper (1941, pp. 6-10) cite figures demon-

strating this from several points of view. It is shown, for example, that

arrests for major offenses amount to 2.68% of all nineteen-year-old males

in the population. This age, nineteen, appears to be particularly crucial

in their several tables. From age sixteen through age nineteen, there is

a sharp increase in arrests for serious offenses, with subsequent decline

to age 25, though this is not true when all offenses, including traffic vio-

lations, drunkenness, etc., are taken into account.

Any existing conflict over difference is sharply accentuated at this

period, when so many changes confusing to the adolescent's judgment of

himself are taking place. Aggression, often based on real hostility, flares

up and may lead to delinquent acts which may have any of several values

to the adolescent. Delinquent behavior may operate to demonstrate to

the adolescent and to others his masculinity ; it may be a carry-over of

rebellion against family authority (father) to all forms of authority; it

may represent revenge on the family, perhaps a particularly infantile

method of returning to an earlier dependent state ; it may have simpler

values with reference to economic factors, in the absence of long-time

goals; occasionally it represents a need for failure and punishment. A

great deal of the delinquency in this period, however, in so far as it is an

expression of personality as opposed to social factors, is a matter of

compensation for the conflict over difference.

It is within this area that intellectual inferiority, with inadequate pro-

vision for educational potential, is especially important. Pressures for

success and conformity in standard educational procedures, derived from

the family, the school, and class competitions, frequently operate to force

8x6 PERSONALITY AND THE BEHAVIOR DISORDERS [26

the inadequate individual toward delinquent behavior as a means of com-

pensation for his own feelings of inadequacy, and as proof to the group

of his adequacy.

IDENTIFICATION. Sometimes delinquency may be shown to be equiva-

lent to identifying with the group. Under such circumstances the indi-

vidual merely takes over the pattern of the family or the neighborhood

and has no special feelings of guilt or anxiety about his behavior. The

need for a "hero" (ego-ideal) is well known, as is the tendency to identify

with the most widely publicized individual of the neighborhood or a

larger community.

Under the most favorable circumstances, the ego-ideals are derived

(at least primarily) from father or mother, who represent not only

authority, but also competitive careers. In case the family or neighbor-

hood pattern is chiefly one of delinquency, then for a child to go contrary

to this pattern would certainly produce conflict and at least some symp-

toms of abnormality. There is much evidence to the effect that there are

delinquency areas, in the sense that an unusually high proportion of

children in such areas appear in court. However, even_in such areas,

there are many nondelinquents, always, so far as known, exceeding the

Delinquents in number. -.-..,- -

It should be noted that many instances could be cited in which the

child reverses the patterns of parents or neighborhood, apparently in

reaction to other identifications from which the super-ego is derived.

FAMILY SITUATIONS. The most important factors leading to delin-

quency are undoubtedly to be found in the variations of the "family

drama," those interpersonal relationships so important during the early,

formative years.

Some studies have attempted to show that the "broken home" is a

basically important factor, chiefly in terms of incidence among delin-

quents, without adequate controls. Clinical experience has, however,

amply demonstrated that it is not the broken home as such which is

directly responsible, but the reactions of the individual which are impor-

tant. Thus it can be shown in case after case that a psychologically

broken home, with disharmony, quarreling, and the use of the child as a

buffer between parents, is far more important in determining attitudes

conducive to delinquency than are actual, physical breakdowns in the

makeup of the family.

Another family situation often studied is that of the ordinal positions

of the delinquent among siblings. Particularly, the only child has been

studied, primarily, apparently, because of a general idea that the only

child is necessarily indulged, and so is not stimulated to (a) grow be-

yond the original narcissism so far as love object relationships are con-

cerned; or (b) learn to forego the pleasure of the immediate future in

favor of more remote gains. J^jtefinite evidence has LjLbeen produced

to indicate that the only child is more liable to delinquency than any

26] DELINQUENT AND CRIMINAL PERSONALITIES 817

other child in the jfamily setting. A recent study by Hart and Axelrad

l[T94rj points to some differences in personality traits among delinquent

boys who are only children or members of large families, but there is

definite indication that family size is not the important item. Common

observation shows that, from the psychological standpoint, several or all

of a family of children may occupy an "only child" situation. This is

clear for all oldest and youngest children ; because of spacing and changes

in sex of succeeding children, it may apply to all in a particular family.

The factor of rivalry and jealousy among siblings is of considerable

importance. Of practically universal occurrence, whether or not it be-

comes sufficiently marked to be related to delinquent behavior apparently

depends to a great extent upon parental recognition and management.

The most important family situations have to do with emotional

relationships, especially those subsumed under rejection, as felt by the

child, or overprotection, as expressed by the parent. Ordinarily the child

derives early ego-ideals, feelings of personal adequacy, security in the

group, evidences of affection, and love objects from the family group. In

case of severe family disharmony, none of these needs may be satisfied.

Particularly, the child may actually be rejected or may be made to feel

that he is rejected. He may find no anchorage for his affectional needs,

nor stimuli to become less narcissistic. These feelings of being unwanted,

neglected, thwarted in self-expression, and of insufficient importance to

lead to stable, adequate, and consistent discipline in the home, produce

a variety of feelings of insecurity and inadequacy which may be impor-

tant in the evolution of a delinquent career.

Overprotection operates in a somewhat different way, since no pen-

alties are exacted for transgressions and many aggressive reactions run

on. That being the case, there is no particular super-ego formation ; in^

fantile hedonistic egocentricity is not checked; there is no stimulus to

accepting personal responsibility, since someone else always assumes it.

Normally developing sexuality is likely to be checked. Not infrequently

it happens that such overprotection operates to make the child feel that

he is not valued (as frequently he is not, much overprotection springing

from parental guilt feelings over rejecting the child), since limits are

not consistently set for him as they are for other children he knows,

whose family relationships seem less strained than his.

AGGRESSION, HOSTILITY, AND FRUSTRATION. These mechanisms are

particularly ascribed to the delinquent, probably because so many crimes

involve "acts of aggression" toward the person or property of others.

Essential to the development of hostile aggression is frustration. Simple

aggression or hostility have other meanings in terms of personality

makeup (Lowrey, 1938) but where many frustrations are in evidence,

either or both may rise to the point where the resulting behavior re-

actions are distinctly delinquent in type. Especially important are the

frustrations arising in the family, interfering with normal identifications,

8i8 PERSONALITY AND THE BEHAVIOR DISORDERS [26

love relationships, and the development of the sense of personal adequacy

and group security. Frustrations arise from parental rejection, sibling

rivalry, and oversolicitousness. The resultant hostility is due to the in-

ability to accept the unfavored position, or to uninhibited ego evaluation.

PSYCHOSEXUAL DEVELOPMENT. Various abnormalities in the course

of psychosexual development are frequent in delinquents. These have

chiefly to do with problems in relationships, especially object love rela-

tionships. Here again, family experiences are extremely important. It

is quite characteristic of the delinquent that the capacity for lasting,

friendly, emotional relationships is greatly diminished or absent.

In cases where sexual delinquency predominates, various difficulties

in personality development, either constitutional or acquired, are usually

found. However, many individuals presenting similar physical or mental

findings achieve an adequate sublimation.

GENERAL PERSONALITY CHARACTERISTICS. The delinquent person-

ality is, in general, characterized by immaturity, egocentricity, and

inability to establish emotional relationships with others, primarily

because of lack of ability to identify or because of actual hostility.

By immaturity is meant a failure to develop in various ways, aside

from mensurable biological inferiorities. Specifically, inability to restrain

present impulses to pleasurable activity in the face of imminent penalty,

or in favor of long-time goals ; inadequate control of emotional reactions ;

and lack of poise and balance commensurate with age and position are

some of the ways in which immaturity is shown.

Egocentricity appears in the search for personal pleasure, lack of

consideration for others, absence of sense of guilt, often resulting in

blaming others for difficulties really dependent on the individual, and a

carping, critical attitude toward others. Not only does the delinquent

tend to believe he is right and others wrong, but he feels that his emo-

tional outbursts should be accepted without complaint by others. General

moral and ethical ideas are considered only in the light of their advan-

tages to the self.

It has been noted that there is a tendency for the delinquent to become

stabilized, i.e., to mature emotionally, at about age 30 (for example,

Foxe, 1938). This is true of nondelinquents as well, and is probably an

expression, for both groups, of maturational factors so important in per-

sonal and social adjustment at different ages.

To sum up, a great many factors have been found important in the

evolution of the personality of delinquents. Not one is peculiar to the de-

linquent. The most important points are found to be factors leading to

increased hostility, egocentricity, and lack of consideration for others.

These may depend primarily on abnormalities of constitution, or upon

the effects of early, distorted, or thwarted relationships in the family or

its substitute. Delinquency is probably most frequently due to the subtle

effects of interactions between individual and environment, leading to the

establishment of particular personality sets.

26] DELINQUENT AND CRIMINAL PERSONALITIES 819

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26] DELINQUENT AND CRIMINAL PERSONALITIES 82:

NORTH, E. A. 1940. Psychopathic personality. Dis. nerv. Syst., 1, 136.

NOYES, A. P. 1934. Modern clinical psychiatry. Philadelphia: Saunders.

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conceptions. /. Amer. med. Assn. t 61, 2119.

Chapter 27

UNFIT PERSONALITIES IN THE MILITARY

SERVICES

By A. WARREN STEARNS, M.D.

IT is DIFFICULT TO SAY when the concept of personality disorder first

came into the human mind. Insanity and mental deficiency have long

been recognized. References to mental disease and defect date back to

the very remote past. The earliest references to what now seem to have

been psychopathic personalities appeared under the heading of moral

lunacy. Battie, who published in 1758, mentions nothing which could be

so classified. However, Benjamin Rush, in 1812, speaks of an oration

delivered before the American Philosophical Society in the year 1787

as giving an account of the nature and offices of the moral faculty of

conscience. He gives several cases, three of which had come to his atten-

tion, and says, "How far the persons whose diseases have been mentioned

should be considered responsible to human or divine laws for their action

and where the line should be drawn which divides free agency from

necessity and vice from disease I am unable to determine." Moreover,

Sampson, writing first in 1841, gives an excellent case, which would

seem to indicate that at least as early as 1819 the problem was a vexing

one.

In the Richmond Lunatic Asylum, Dublin, Mr. George Combe

saw a patient in 1829, who had been confined for ten years. He ex-

hibited a total want of moral feeling and principle, yet possessed con-

siderable intelligence, ingenuity, and plausibility. He had been a

scourge to his family from childhood had been turned out of the

army as an incorrigible villain had attempted the life of a soldier

had been repeatedly flogged and had since attempted the life of his

father. Respecting this man, Dr. Crawford, Substitute Physician at

the Asylum, made the following remarks : "He never was different

from what he now is; he has never evinced the slightest mental inco-

herence on any one point, nor any kind of hallucination. It is one of

those cases where there is great difficulty in drawing the line between

extreme depravity and insanity, and in deciding at what point an

individual should cease to be considered as a responsible moral agent,

and amenable to the laws. The governors and medical gentlemen of

the Asylum have often had doubts whether they were justified in

keeping him as a lunatic, thinking him a more fit subject for a Bride-

well. He appears, however, so totally callous with regard to every

822

27] UNFIT IN THE MILITARY SERVICES 823

moral principle and feeling, so thoroughly unconscious of ever having

done anything wrong, so completely destitute of all sense of shame

or remorse when reproved for his vices or crimes, and has proved

himself so utterly incorrigible throughout life, that it is almost certain

that any jury, before whom he might be brought, would satisfy

their doubts by returning him insane, which, in such a case, is the

most humane line to pursue. He was dismissed several times from the

asylum, and sent there for the last time for attempting to poison his

father; and it seems fit he should be kept there for life as a moral

lunatic: but there has never been the least symptom of diseased

action of the brain, which is the general concomitant of what is

usually understood as insanity. This, I consider, might with pro-

priety be made the foundation for a division of lunatics into two

great classes those who were insane from original constitution, and

never were otherwise and those who have been insane at some

period of life from diseased action of the brain, either permanent or

intermittent.

Prichard, writing in 1835, is frequently given as the originator of the

concept of moral lunacy. A careful reading of his chapter on moral in-

sanity, however, would seem to indicate that it has nothing to do with

constitutional inferiority, but is an attempt to group mental diseases

according to emotional differences. The cases given would appear to be

what are now called dementia praecox and manic depressive insanity.

Most psychiatric works from this time on grapple with this problem.

As early as 1817 the Habitual Criminal Law was passed in Massachu-

setts recognizing that there are certain individuals who were prone to

commit crime. Meanwhile, Lombroso (1911), and other members of the

positivist school had developed the idea of a born criminal. Their belief

was that this was an atavistic matter and they laid great stress upon

physical stigmata of degeneration. Many went so far as to claim that

by an examination and measurement of a child they could predict his

future criminal life. Partridge (1930) states that, "The wider concep-

tion of psychopathic inferiority dates from Koch's statement in his Leit-

jaden der Psychiatric (1888) and in his Psychopathische Minderwertig-

keiten he refers to this as a new term/'

Maudsley, in 1876, states, "Many cases of moral insanity will be found

to be connected with more or less congenital moral defect or imbecility."

Spitzka, in 1883, states, "Disorders of the moral sentiments may be con-

genital and equivalent to partial imbecility, as the father of American

science, Rush, first pointed out." Later, speaking of moral insanity,

Maudsley suggests that moral imbecility would be a better term. Nisbet,

in 1893, states, "Without being positively insane, a person may have

what is called the insane temperament, a condition characterized by

singularities of thought, feeling, and action. He is eccentric in his habits ;

he does apparently purposeless acts, and he is often either extremely

obstinate or given to violent fits of temper. Rarely, he lands in an

asylum. . . . Moral insanity is another name given to insane tempera-

ment. The deficiency of moral feeling may be of a different kind, or it

824 PERSONALITY AND THE BEHAVIOR DISORDERS [27

may be an ordinary deficiency analogous to lack of musical sense or color

blindness."

In 1904, Dr. Walter E. Fernald stated the following:

To a trained observer the class of boys and girls in truant

schools and in industrial and reform schools includes a rather large

proportion of defectives where the intellectual defect is relatively

slight and is overshadowed by the moral deficiency. The history of

a case of this sort during infancy and early childhood, from a medi-

cal and psychological standpoint, is that of an abnormal child. While

they generally present definite physical evidences of degeneracy, they

are physically superior to the ordinary imbecile. Their school work

is not equal to that of normal boys of the same age, but they are

often abnormally bright in certain directions. They may be idle,

thievish, cruel to animals or smaller children, wantonly and sense-

lessly destructive and lawless generally. They are often precocious

sexually and after puberty almost always show marked sexual de-

linquency or perversion. They are often wonderfully shrewd and

crafty in carrying out their plans for mischief. They instinctively

seek low company and quickly learn everything that is bad. They

have little or no fear of possible consequences in the way of punish-

ment. They acquire a certain spurious keenness and brightness and

possess a fund of general information which is very deceiving on

first acquaintance. They are apt to be accomplished liars. The great

army of police court chronic criminals, vagrants and low prostitutes

is largely recruited from this class of "moral imbeciles/' These

children are not simply bad and incorrigible, but they are irrespon-

sible by reason of the underlying mental defect. The mental defect

and the moral lack are alike the visible effects of incurable affection

of the cerebral cortex. No method of training or discipline can fit

them to become safe or desirable members of society. They cannot

be "placed out" without great moral risk to innocent people. These

cases should be recognized at an early age, before they have acquired

facility in actual crime, and permanently taken out of the community

to be trained to habits of industry and as far as possible contribute

to their own support under direction and supervision. They are not

influenced by the simple system of rewards and deprivations which

easily serves to control the conduct of the feebleminded. They do not

class well with the rather simple types of ordinary imbecility. When

the actual number of this dangerously potential class of moral im-

beciles is fully realized, they will be given lifelong care and

supervision in special institutions combining the educational and de-

velopmental methods of a school for the feebleminded and the

industry and security of a modern penal institution. Such provision

would only be a rational extension of the principle of the indeter-

minate sentence, and, if safeguarded by careful and repeated expert

examination and observation, could do no injustice and would greatly

diminish crime in the immediate future.

Also, in 1908, Dr. Walter E. Fernald wrote:

The patients described vary greatly in intelligence and in the

amount of definite knowledge which they have acquired, but they

27] UNFIT IN THE MILITARY SERVICES 825

greatly resemble each other in their childish tastes, excessive vanity,

unreliability, aggressive boastful egotism, selfishness, moral insensi-

bility, fondness for malicious mischief and trouble-making, indolence,

willingness to run great risks for the sake of some small gain, un-

truthfulness, lack of shame and remorse, lack of sympathy, etc.

The cases described fairly represent the criminal imbecile type.

I have no doubt as to the actual imbecility and the resulting moral

irresponsibility of every one of these cases. As a group, the female

cases especially well illustrate the so-called "high-grade imbecile."

In fact, the physical and psychical stigmata exhibited by this group

of imbeciles, selected because of their criminal tendencies and acts,

are merely the usual signs and symptoms found in the ordinary case

of imbecility, modified only in degree and not in mind.

This class of borderline cases with criminal tendencies now con-

stitutes a troublesome and puzzling factor in our institutions for the

feebleminded. They are often malicious, deceitful, and inciters of

mischief and insubordination. They have a wonderful power of

suggestion over their simple-minded fellow-patients. They are gen-

erally committed to the institution against the wishes of their parents.

The efforts of their friends to obtain their release are constant and

perplexing. If a case of this description is taken before the Supreme

Court on a writ of habeas corpus, it is more than likely that the

patient will be released. Indeed, it is not difficult to find reputable

medical men who would testify that the case "is by no means a fool,"

and that he ought not to be deprived of his liberty. It is evident that

clinical types and shadings of mental deficiency have become familiar

to the alienist which have not yet been so definitely formulated and

classified as to be readily recognized by the profession generally. It

is equally true that the legal definitions and precedents pertaining to

ordinary cases of imbecility are inadequate when applied to these

high-grade imbeciles. We have, therefore, to face the anomalous

fact that it is easy to have a class of patients committed to our in-

stitutions who are promptly discharged by the higher courts because

these lesser types of deficiency have neither been adequately formu-

lated nor recognized legally.

Dr. Guy Fernald, in 1912, wrote the following:

There is urgent need of special legal recognition of the class of

defective delinquents, and of suitable provision for their proper com-

mitment and permanent detention. The law should recognize that

such a class exists by making a distinctive legal definition. There

should be a definite form of procedure for the commitment of the

defective delinquent similar to that used for the commitment of the

insane. This procedure should be equally applicable to cases in the

courts or in the community, to youthful and adult criminal defectives,

and to cases which develop in the institutions for the feeble-minded.

They should be committed to permanent care and custody, under spe-

cial institutional conditions combining the educational and develop-

mental methods of a school for the feeble-minded with the industry

and security of a modern penal institution. Under proper conditions,

perhaps in a farm colony, the directed labor of these persons would

826 PERSONALITY AND THE BEHAVIOR DISORDERS [27

materially reduce the cost of their support. Their immoral and

criminal depredations would be prevented, the cost of repeated ar-

rests, trials and commitments would be avoided, and they would not

be able to bring helpless children into the world. Provision should

be made for the safeguarding of the rights of the individual by peri-

odical expert examination and observation, and by the possibility of

ultimate release under parole.

From this time on constitutional inferiority and constitutional psycho-

pathic inferiority are frequently found in American psychiatric literature.

Dr. May, again according to Partridge (1930), states that Dr. Meyer

told him that he used the term psychopathic inferiority in connection

with the Thaw case in 1908. By 1910, it was customary to classify indi-

viduals committed to hospitals for mental disease who were neither

feebleminded nor insane, but whose conduct was extremely disordered,

under the heading "constitutional inferiority." The concept at that time

was not especially different from our present concept, but more emphasis

was put upon evidence of nervous irritability during early childhood

and upon evidence of physical inferiority. In the author's study (1914)

of the population of the Bridgewater State Hospital for criminals, nine-

teen such individuals were found to be committed there as insane, usually

because of the commission of atrocious crimes.

At the time of the opening of the Boston Psychopathic Hospital in

1912, American psychiatry was very much under the influence of Krae-

pelin, who spoke of congenital states of morbid personalities, morbid

criminals and born swindlers. However, he later clarified the matter by

speaking of psychopathic personalities and divided them into the para-

noid, inadequate, and emotionally unstable. This classification was current

for some years, but the last war resulted in a recurrence of constitutional

inferiority and many constitutional psychopathic states.

For many years there have been occasional case studies such as "Jesse

Pomeroy" by Folsom; Haberman's "A case of psychopathic constitu-

tion resembling so-called moral insanity" ; and more recently, Thorn's

"A case of juvenile delinquency." During recent years many writers

have sought to clarify the matter by elaborate psychopathological studies

(see Kahn, 1931 ; Partridge, 1930; Kraepelin, 1915 ; Healey, 1936; Preu,

Chapter 30; and many others). More recently Alvarez (1942) has used

the term constitutional inadequacy to cover a certain number of chronic

nervous invalids.

Cases Seen in Military Service

With the onset of the war the writer, in charge of a neuropsychiatric

service in a naval hospital, was forced to deal with the matter in a prac-

tical way. Patients were daily being received who did not show gross

physical disease, who were not insane or feebleminded, and yet who

had shown vagaries of conduct making them appear undesirable as mem-

bers of the Navy. Of the first 500 admissions, 16% were classified as

27] UNFIT IN THE MILITARY SERVICES 827

personality disorders, to use the Navy nomenclature. No attempt was

made at exactness in terminology. Those cases who were neither insane

nor feebleminded but who showed persistent vagaries of conduct were

assumed to be psychopathic and placed in this group. The following is

the classification used in the U. S. Navy Diagnostic Nomenclature

(1938).

1501. Constitutional psychopathic inferiority without psychosis

1502. Constitutional psychopathic state, criminalism

1503. Constitutional psychopathic state, emotional instability

1504. Constitutional psychopathic state, inadequate personality

1505. Constitutional psychopathic state, paranoid personality

1506. Constitutional psychopathic state, pathological liar

1507. Constitutional psychopathic state, sexual psychopathy

One who uses this concept extensively is faced with a dilemma. Most

individuals whose conduct departs widely from the conventional pattern

show certain constitutional tendencies which may be called psychopathic.

Yet, there is little sense in substituting the word psychopathic for crim-

inal or pauper. At best, the concept in its application seems to be entirely

behavioristic. At one end of the scale we have those who are so erratic

in their conduct that they cannot get along in the most carefully regu-

lated environment. At the other end of the scale we have those so well

adjusted that they can meet the vicissitudes of the most adverse environ-

ment. Where shall we draw the line between the medical problem called

the psychopathic and the social problem called normal? Obviously, a

decision must be made arbitrarily. It is the writer's belief that certain

criteria should be insisted upon. In other words there should be some

evidence that the disorder is constitutional, e.g., a tendency such as steal-

ing or homosexuality which can be traced from early childhood, or else

the reaction being so out of line with what might be expected as to justify

a belief in a psychopathic constitution.

The following analogy has been a help in understanding the concept.

If a man is six feet in height, we characterize him as tall ; if he is six

and a half feet we say he is very tall ; but if he is ten feet in height we

no longer use the ordinary standards by which bodily height is expressed,

but use the term giant, implying the existence of a morbid process. Like-

wise, if a person is short enough there comes a time when we call him a

dwarf, inferring the existence of a monstrosity. If we assume as normal

and healthy a child who develops through its first few years according to

a fairly definite schedule, who upon going to school progresses along

with the other children and gradually tends to mold his conduct like that

of other children, after which he goes through the adolescent period with

only minor changes and embarks upon adult life, gets a job at which

he specializes and excels, establishes a home and from then on leads a

conventional life, we are forced to consider variations from this conven-

tional pattern as abnormal. These variations may be due to intellectual

defect which is a fairly well established concept at the present time, or

828 PERSONALITY AND THE BEHAVIOR DISORDERS [27

the development of a psychosis, where again we have fairly definite

criteria. If neither of these conditions is found we have two possibilities

left, a normal reaction to an abnormal environment, or an abnormal re-

action to a normal environment. Unfortunately, the abnormal environ-

ment and the abnormal personality are often associated and it comes

down to a matter of individual judgment as to with which we are dealing

(see Chapter 24 by Paris).

It is obvious that we can have as many types of eccentric people as

there are human traits. Their only common denominator is that they

behave ineffectually. There are certain inadequate personalities, aesthetic

in type, lacking in drive, who do not meet their obligations and frequently

resort to alcohol or a neurosis as an escape. These, of course, are closely

related to Kraepelin's inadequate personalities as well as to Alvarez' con-

stitutional inadequacies. The individuals in another group are well, but

they also lack drive, or they are emotionally unstable and so have diffi-

culty in making the sustained effort to support themselves and have to be

assisted by friends or relatives or the public. The members of still another

group are from their earliest days rebellious and intractable (the trouble-

makers) and have all the other characteristics so frequently described as

criminal. If 50% of the population are so constituted, obviously the

concept has no validity, as they are just average people. In other words,

it is folly to extend the group to include all of the social problems of

society. It should be reserved for persons who stand out grossly as

variants.

Illustrative Cases. It must be confessed that an attempt to abstract

cases shows the use of the concept by us to have been largely utilitarian.

A study of the record of the individual and an analysis of the episode

which led to his coming to the hospital has convinced us that it would be

imprudent to send him back to duty. Whereas some of this group would

undoubtedly make good, they belong to a category which as a group

offers little promise. A gleaning of a few data from the cases following

will perhaps help to show the sort of problems that have occurred al-

though fuller case study makes it very difficult to find "the least common

denominator" in these cases.

H. D. V. Sent in because of tendency to seek a weapon when he lost

his temper. Much trouble in the Navy through violent attempts upon others

with weapons. A haughty, belligerent, egoistic, individual, thoroughly un-

reliable on the ward, a bully and a petty thief.

T.J.F. A sneak thief with many -house-of-correction sentences, lived

with prostitutes at their expense; traveled in a carnival, ran away shortly

after enlistment.

B. F. A somewhat talented, artistic person who went to theological

school, left after a short while, when he became involved in a homo-

sexual episode. Then entered law school, stayed one term. Went to theo-

logical school of another denomination and gave up after a short while.

Enlisted in Army and in a few months bought out, then enlisted in the

Navy, very unhappy, discontented, talked of suicide, and said he couldn't

27] UNFIT IN THE MILITARY SERVICES 829

stand it. Given medical discharge. Went to another theological school,

stayed a little while, and again changed his mind.

A. G. Backward in school, borderline feebleminded, irregular work at

odd jobs. Wife works steadily. Shortly after enlistment, while on guard,

shot himself with a 30-30 rifle through the foot. Very much depressed,

soon cleared up and not considered psychotic.

S. A. H. Somewhat of a problem child, left high school against parents'

wishes, returned a year later, started college and gave it up to join the

Navy. Contracted gonorrhea and syphilis from one exposure. Very much

depressed, took poison and nearly killed himself. Sent to hospital as manic-

depressive. Soon cleared up.

/. H. On parole from state reform school, a roamer and persistent

parole violator, petty thief, deserted soon after enlistment. Very dull, bor-

derline feebleminded.

V.M.N. Committed to a reform school in early childhood, frequent

runaway and parole violator, said not to be vicious but intractable and un-

dependable. Returned from abroad for refusal to obey orders. Borderline

feebleminded. Ran away from hospital.

R. F. M. Two years of high school, involved in domestic friction at

home, left school because of grief over parents' quarrels. Shy, easily

fatigued, complained of his stomach. In brig for going to sleep while on

watch, which he persistently did. Many somatic complaints suggesting

psychoneurosis.

R. C. 0. States that he has never been attracted by females, and since

15 years of age has habitually had sexual satisfaction with males. No diffi-

culty in Navy but in acute anxiety state for fear he might get into trouble

and be sent to prison.

G. /. O. Backward in school, borderline feebleminded, frequently runs

away. One term in reformatory, deserted from Army and ran away shortly

after entering Navy. Many complaints suggesting neurosis. Dizziness,

headache, and so on.

E. W. 0. Left third year of high school to enter Navy, very homesick,

seasick, and couldn't stand duty on tanker as member of gun crew. Cried,

very unhappy, and talked of suicide but cleared up promptly in hospital.

C. H. P. Sent in for headache, having been A. W. O. L. complained of

headache, indigestion, and history showed that he had always been asthenic,

frequently going to doctors as a child. Caused neurasthenia but difficulty

appears to be constitutional. His previous instability was carefully verified

but he has recently written in saying that he lied about his headache and

now wishes to join the A-rmy and asks help in getting him in.

/. H. R. Backward in school, worked with father, drank creosote in

brig while awaiting trial for being A. W. O. L., ran away from hospital,

cried when discussing problem, yet he immediately did it again and also

drank Clorox while in the brig.

A. D. A. Many arrests for vagrancy bad conduct discharge before this

enlistment. Ten days A. W. O. L. Alcoholic. Sent in with a question of

alcoholic delirium. Surveyed C. P. S. without psychosis.

A. J. A. Backward in school, professional fighter, alcoholic. Much naval

disciplinary trouble. Sent in from the brig of his ship for scabies. Returned

to duty, no disease, but subsequently showed utter irresponsibility. Should

have been called C. P. I.

J.P.A. Upon going to sea was very much frightened, so frightened

830 PERSONALITY AND THE BEHAVIOR DISORDERS [27

by gunfire that he could not perform his duty. A dull, asthenic individual,

who went two years to high school. Simply lacking in the stamina required

for military duty.

/. W. E. A somewhat dull man, completed ninth grade at 17. During

any excitement went into hysterical attacks. On one occasion was mute for

several days. On another occasion, frenzied excitement, particularly upset

by gunfire.

R. S. F. Sent in under arrest for homosexual advances. Entertainer at

night club, bell boy in hotel, roamer. States that at 15 had first homosexual

experience. Women never attracted him, males always. Somewhat effemi-

nate in his manner.

B. E. C. An adopted child who graduated from high school, worked with

his foster father in a female beauty parlor; on the stage in the evening im-

personating a female ; picked up spare money by prostitution to male homo-

sexuals. Admitted in acute anxiety state afraid he would transgress in

Navy and get sent to prison.

E. M. B. A persistent runaway at home, irregular attendance at school,

petty thief diagnosed as kleptomaniac before enlistment. Ran away 10 days

after enlistment. Suicide attempt in brig.

D. G. F. Previous history negative. At 21 fell in love with a 16-year-

old girl whose parents would not consent to her marriage. Much friction

because girl did not marry him. He went out into a park, cut his wrists,

and drank sulphanaphthol.

F.X.B. Began stealing in early childhood. During high school forged

checks and ran away and enlisted in Marines. Ran away and was sent to

hospital where he again escaped. Attempted suicide by gas. Following a

medical discharge he enlisted in Navy; immediately ran away, and again

attempted suicide and was sent to this hospital.

7. /. D. A good boy, devoted to his mother, became discouraged over

failure to get a type of transfer he wished. Given leave, went home, some-

what sad, hated to go back. Brother took him to train, later found him in

the evening in an alleyway with both wrists cut and having drunk a bottle

of mercurochrome. Cleared up rapidly in hospital. Did not appear to be

psychotic.

W. J. D. Eighth grade at 16. A runaway and a petty thief, committed

at 14 to state reformatory during minority, and in and out of this and other

reformatories. Five commitments to hospitals for mental disease for obser-

vation. Only work as laborer at carnivals. Married to a similar character.

Enlisted and soon ran away.

F. F. I. A problem child, a runaway from home. In early youth com-

mitted to reformatory at age 10. Frequent runaway, characterized by

police as worst man in town. Traveled with circus and carnivals, no steady

work. When attempt was made to take blood from his arm, he went into

hysterical convulsions. Petty thief.

F. J. C. At 10 years of age in juvenile court ; 75 arrests in Suffolk

County, discharged from Navy as undesirable in 1917. Has had commit-

ments to seven different hospitals for the insane, usually for observation

and delirium tremens. Has served sentences in at least four different

prisons. Little or no work.

WW.K. Problem child, juvenile court, many arrests usually for

drunkenness and wife beating. Irregular employment. Enlisted when drunk

and immediately ran away.

27] UNFIT IN THE MILITARY SERVICES 831

J. E. P. A dull boy who had nearly finished high school, constant corn-

plainer, considered an invalid, only job as errand boy. Left school because

his eyes hurt, unable to keep up with others in the Navy and sent to hospital

on account of eyes. Considered inadequate personality.

/. C. A. A backward person in school, family on welfare. Several trips

on the Merchant Marine. No steady work. Walked and talked in sleep.

Frequent runaway, enlisted in Navy, ran away from training station, at-

tempted suicide when put in brig for punishment.

E. /. A. Backward in school, on parole from reformatory when enlisted.

Committed to state hospital as insane in 1940 during an episode. While in

our brig refused food, stood mute in fixed posture for several days, at-

tempted suicide. Spent a day or two making rhythmic motions, saying the

same thing over and over again, suggestion catatonia. Cleared up promptly.

Considered C. P. I. with psychosis.

R. O. B. Expelled from high school, roamer, petty thief, pathological

liar, posed as a college man and borrowed all the money on the ward. Prob-

lem child. Ran away shortly after enlistment.

E. L. B. Subject to outbursts of temper. Habitually sought a weapon

during these outbreaks. In many courts and fighting; all the traits of the

feebleminded, with IQ of 75. Cried violently if sad, or into a frenzy if

irritated.

/. B. Juvenile delinquent, backward in school, persistent runaway. En-

listed in Navy and almost immediately ran away. Rebellious and intractable.

E. P. C. Race track habitue, made his living as a pimp and petty gam-

bler. Alcoholic. Lived on the income which his wife received as a prosti-

tute. Ran away shortly after enlistment.

R. J. C. Backward in school, good family, on probation for breaking

and entering when enlisted. Many arrests for petty offenses. Rebellious at

home. Ran away shortly after enlistment.

/. E. C. Backward in school, many jobs of short duration. Quarrelsome

and unmanageable at home. Deserted shortly after enlistment.

A. M. D'A. Committed to reform school as a stubborn child at 12. Per-

sistent parole violator and petty thief. Borderline feebleminded. IQ 71.

Deserted shortly after enlistment. Ran away from hospital.

HS. Said to have received a head injury as a child. Ran away from

home at 10 and roamed throughout the United States traveling on freights.

No known arrests, undesirable discharge from the Army in June, enlisted

in Navy in September and soon ran away; ran away from hospital.

P. /. Z. Backward in school, frequent truant on probation in juvenile

court, discharged from C. C. C. for disciplinary reasons. A nomad, admitted

to the hospital once, worked well, and returned to duty but after 10 days

ran away. Attempted suicide by hanging in brig.

C. S. Y. An older man, aged 53, enlisted as 46. In the Army in last

war. Father was a doctor and mayor of a large city in West. Ran away

at 16 and has never seen his family since. A soldier of fortune roaming

all over the face of the earth as a common sailor and for last 16 years as

a stunt man in Hollywood. Lived alone, had little or nothing to do with

other people, no friends, paranoid, egoistic, vain, very proud of his body and

his exploits. Called "Pap" by sailors which led to frequent outbreaks of

temper. Thought he was being discriminated against by everybody.

S. C. Several arrests as a young man, served one sentence in prison.

In 1937 when out of work and in domestic trouble had period of amnesia

832 PERSONALITY AND THE BEHAVIOR DISORDERS [27

lasting 12 days, brought to hospital by shore patrol in cataleptic state, did

not speak for several days, cornea insensitive, claims amnesia for period

of about 10 days. Had recently served a sentence in brig for A. W. O. L.

and a fine of $150. Now cleared up completely but still claims amnesia.

/. H. S. Background excellent, a normal, healthy young man, homesick,

returned to his home and told his parents that he had leave, stayed two

weeks, started back for ship and 10 days later was brought to hospital

claiming that he did not know his name or who he was. Now cleared up

but still claims amnesia for period of about two weeks.

It will be noted that of these 42 cases, 20 were definitely problems of

delinquency; 16 were problems of emotional instability; and but three

were sexually peculiar. There were but two who appeared to be defi-

nitely sick, and only one who was paranoid. It is quite obvious that had

we been working on a medical service, especially with the gastrointestinal

group, we would have had a very much larger number of sick and a

smaller number of delinquent cases.

In studying large groups of incompetent people the writer has for

many years used the gross subdivision of the sick, the poor and the bad.

This may be a good way to classify personality disorders. It is certain

that in the Navy part of them come to the attention of the disciplinary

officers because of delinquency ; another part are problems for the divi-

sional officers because of inaptitude, and an unknown number are at the

sick bay projecting their disabilities into symptoms of physical disease.

BIBLIOGRAPHY

ALVAREZ, W. C. 1942. Constitutional inadequacy. /. Amer. med. Assn., 119 t

780-783.

BATTIE, W. 1758. A treatise on madness. London: J. Whiston & B. White.

FERNALD, G. G. 1912. The recidivist. Amer. J. Insan., 68, 866-875.

FERNALD, W. E. 1904. Care of the feeble-minded. In National Bulletin of Chari-

ties and Corrections.

1908. The imbecile with criminal instinct. Amer. J. Insan. 65, 731-749.

HEALEY, W. 1936. New light on delinquency and its treatment. New Haven:

Yale University Press.

,KAHN, E. 1931. Psychopathic personalities. New Haven: Yale University Press.

LOMBROSO, C. 1911. Crime, its causes and remedies. (Trans, by H. P. Horton.)

Boston: Little, Brown.

MAUDSLEY, H. 1876. Responsibility in mental disease. New York: Appleton-

Century.

PARTRIDGE, G. E. 1930. Current conceptions of psychopathic personality. Amer.

J. Psychiat., 10, 53-99.

PRICHARD, J. C. 1835. A treatise on insanity and other disorders affecting the

mind. London: Sherwood, Gilbert & Piper.

RUSH, B. 1812. Medical inquiries and observations upon the diseases of the mind.

Philadelphia : Kimber & Richardson.

SAMPSON, M. B. 1841. Criminal jurisprudence considered in relation to cerebral

organization. London.

SPITZKA, E. C. 1883. Manual of insanity. (2nd ed., 1887.) New York: E. B.

STEARNS, A. W. 1914. A survey of the inmates of the Bridgewater State Farm.

1916. A survey of defective delinquents under the care of the Massachu-

setts State Board of Insanity. Amer. J. Insan., 72, 427-437.

U. S. NAVY. 1938. Diagnostic nomenclature for the Medical Department of the

U. S. Navy. Manual of the Medical Department. Ch. 15, Appendix, p. 53.

Chapter 28

THE PSYCHONEUROSES

By WILLIAM MALAMUD, M.D.

IT HAS LONG BEEN RECOGNIZED by the medical profession, and

particularly by those working in the field of psychiatry, that the

psychoneuroses occupy a unique and important place in the study of

human adjustment. Their frequent incidence, the rich variability of

their clinical pictures, and the fact that they afford a link between the

more serious mental disorders and normal personality functions and be-

tween psychiatry as a specialty and medicine in general make them a

natural starting point for the discussion of mental diseases in the medical

curriculum. In a handbook whose purpose is to present personality

functions and their disorders to a group that extends beyond the limits

of the medical profession, an understanding of the nature, characteristics,

manner of development, and methods of treatment of the psychoneuroses

gains even greater fundamental value for the following reasons :

The Prevalence of Psychoneuroses. It may be said without fear

of exaggeration that the number of persons whose adjustment is inter-

fered with because of the various forms of psychoneurotic disturbances

is greater than that found in any other single type of medical disease

known to the profession. A well-known and reliable specialist in internal

medicine, who was, at the time, the director of one of the largest general

hospitals in the country, estimated that of the entire clientele of the out-

patient department of his institution computed over one year, fully 75%

were suffering either from pure psychoneurotic syndromes or psycho-

neurotic superimpositions upon somatic diseases. Even if this may be an

unusual proportion of the incidence of these disorders, other men work-

ing in the field and equipped with the training and interest enabling

them to evaluate their material properly have varied in their estimates

from a conservative 40% to the high 75% mentioned above (Strecker,

1930; Ebaugh, 1940). When we consider the fact that there are a great

many people in the general population who are afflicted with difficulties

of this type but who rarely consult a physician or particularly one who

specializes in psychiatry, we can form an idea of the high proportion of

individuals who are more or less incapacitated in their adjustment by

psychoneurotic ailments. Any attempt to understand personality dis-

orders, therefore, must include an acquaintance with the nature and

mechanisms of the psychoneuroses.

833

834 PERSONALITY AND THE BEHAVIOR DISORDERS [28

Even if we disregard the question of disorders in the functions of

the personality and deal with the behavior of the average individual, we

are still confronted continually with the need to understand the factors

which have been brought to light by students of neurotic behavior.

Students of normal psychology are well aware that our knowledge of

human behavior, and particularly our knowledge of its dynamics and

motivation, has been greatly enriched by contributions from this field.

The impetus that has been given to the progress of dynamic psychology

by psychoanalysis (see Chapters 3, 6, 7, 8, 9, and 20 in this book), by

studies of experimental neuroses in animals (Anderson and Parmenter,

1941 ; Masserman, 1943; see also Chapters 12 and 13), of war neuroses,

of children's disorders, and others is well known and requires no further

elaboration. If, in addition to the study of personality functions in the

individual, we consider the problems of social pathology and group

behavior in general, we find hitherto isolated but recently more concerted

attempts to understand the disorganization of group behavior on the

basis of what we know takes place in the development of a neurosis.

Such problems as disturbances in morale, class unrest, and the reaction

of the general population to catastrophes have been subjected to analyses

of this kind which have added considerable clarification. For instance,

the studies recently published in England by Glover (1941), Bion

(1940), and Sargent (1940) have shown that the development of

unusual attitudes, anxieties, and resentments in the group can be under-

stood in relation to the stress and strain to which society is subjected in

more or less the same manner in which a psychoneurotic syndrome

develops in the individual.

Paradoxical as it may appear, considering the widespread incidence

of such disturbances and the somewhat glib use of the word neurotic not

only in academic vocabulary but in everyday conversation, there is a sur-

prising lack of unanimity and clarity as to what is meant by the concept

of psychoneurosis, what its limitations should be, to what particular forms

of behavior it should be applied, and under what conditions it develops.

At the outset, therefore, I should like to consider what we might call a

definition of the psychoneuroses and proceed from it to a discussion of

their manner of development, clinical manifestations, differential diag-

nosis, and treatment. To the psychiatrist it is clear that there are certain

cases with syndromes so definite that there is no doubt as to their being

representative of a typical psychoneurosis. Such a syndrome can be uti-

lized here for the purpose of abstracting from it the features that render

it typical of this form of disturbance and with this as a nucleus we can

develop the concept of what the term stands for. With this in mind, I

should like to present the following case :

A 28-year-old married man was brought into a general hospital with the

chief complaint of blindness. The events leading up to his admission were

as follows: Shortly before admission hevjvas involved in a minor automo-

bile accident. The patient apparently sustained only minor scratches, but

directly after the collision he complained of the fact that he could not see.

28] THE PSYCHONEUROSES 835

The hospital examinations failed to show any signs of physical injury

aside from a few abrasions, and no organic reason could be found for the

blindness. He was referred to the psychiatric department with the diagnosis

of Psychoneurosis, Hysteria.

The first interview brought to light the fact that the patient sustained

the accident while driving to visit his wife, who had just been confined

with the first child. His first spontaneous remark was to the effect that

since he was now blind and would probably remain so for life, his first

duty to his wife was to divorce her, thus obviating the necessity of tying

her down to a blind man. A careful physical and neurological re-examina-

tion failed to show any organic basis for this symptom, and an analysis

was undertaken of the life history of the patient in order to understand why

that symptom had developed. Briefly, the facts were as follows: The

patient was an only child. The father was physically of slight build, of a

meek, dependent type of personality, economically unsuccessful. The mother

was the direct antithesis, ample of body and "strong" in character. She

ruled the household with an iron hand, serving both as master and support

of the father and of the patient. The patient had inherited a queer com-

bination of the father's physical characteristics and the mother's indomi-

table and independent character. Early in life, as usually happens, he had

built up his attitude toward the sexes on the basis of his own parents.

His feelings toward them were ambivalent. He liked the sympathetic and

kind father, but pitied his weakness and dependence. He respected the

mother, but at the same time hated her and revolted against her domineer-

ing attitude. Two important factors developed as he reached puberty. Fear-

ing a fate similar to that of the father, he had determined never to get

married. Seeking independence and freedom, he decided to cut away from

horn* and make his own way. He succeeded in this quite well and as far

back fcs early adolescence he became self-supporting in a position that fur-

nished him comfortable means. He adhered to his original decision not to

get m irried, although since he was apparently sexually a normal person he

was attracted to members of the opposite sex. He had several affairs which

invariably took the same pattern. As long as it was a matter of friendship

only or uncompromising sexual contacts, he continued the relationship, but

as soon as any hint of marriage appeared, he found some means of dis-

solving the contact. His present wife was, of course, the last of these

affairs. He became very much attached to her and a unique but under-

standable relationship was established between them. She was very similar

in character to his mother, or at least she appeared so to him, and early

in their contacts he began to seek her advice in business affairs, and let

her make decisions for him. The more he did so, the greater became his

discomfort in her presence, but nevertheless he could not find the necessary

strength to break the relationship. In the course of events she suggested

that they get married and in a weak moment he acquiesced. At his instiga-

tion they had decided that care should be taken to avoid children at least

for a while, although economically he was in a position which would have

permitted the expense necessary for the support of a family.

About two years after the marriage she became pregnant. A qvarrel

ensued and he accused her of deliberately allowing this to happen. He tried

to convince her that she should have an artificial abortion but she refused.

All through her pregnancy, as became apparent in the analysis, he had

hoped that the pregnancy would not mature. The realization came to him

836 PERSONALITY AND THE BEHAVIOR DISORDERS [28

during the analysis that he still had had hopes of some day breaking away

from his wife, but that the birth of the child would place an insuperable

barrier in his way. When she was taken to the hospital for delivery he

spent a few days in his home in great anxiety, conscious of fears that

something would happen either to the wife or to the child. Then the news

came that he was the father of a normal boy and that both the child and

his wife were in good condition. On his way to the hospital after this news,

the accident occurred which resulted in his blindness. As the analysis

progressed he became aware of the reason for the symptom and for his

attitude toward women in general and toward his wife and his mother in

particular. His symptom disappeared but the adjustment of the patient to

the situation became possible only after further interviews not only with

him but with the wife. It became apparent to both of them that his rela-

tionship with her, particularly his dependence upon her and her function of

leader in the family, was something that she did not want at all but which

developed on the basis of the fact that she felt his need and search for

these. With all his natural independence and desire to make his own deci-

sions he was hampered by his early conditioning at home and unconsciously

began to seek these when he met a person who resembled his mother

physically. The discussions with the two resulted in his gaining the position

in the house which he always feared was impossible between man and

woman, and both of them were quite contented in the newly-gained rela-

tionship.

An analysis of the important issues in the above-described case brings

to the fore a series of features which can be regarded as fundamental in

the concept of psychoneurosis. These can be discussed under three main

headings. In the first place, we find a certain manner of development

which logically leads up to the formation of the symptom-complex. Sec-

ondly, we deal with a clinical picture of the fully developed disorder

equally representative of this disease, and finally, we notice the absence

of certain characteristics which led to the exclusion of other types of per-

sonality disturbance. It is true that in the case quoted we are dealing

with a special type of psychoneurotic symptom-complex. In other cases

we may find additional possibilities in etiology and clinical picture. In

the development of our concept of what constitutes a psychoneurosis we

shall first bring to the foreground the essential features in the case quoted

and then add to these such factors as are related to them and are found

in other forms of this syndrome, thus completing what can be designated

as a definition of the concept of psychoneurosis.

Etiology and Manner of Development. A certain degree of impor-

tance must be ascribed to the original personality make-up of our patient.

We spoke in a general way of the fact that this young man had "in-

herited" a combination of characteristics belonging to each of his parents

and that this was of importance in laying the foundation for his subse-

quent attitudes toward life and seemed to be characteristic of him since

the earliest days of his childhood. Whether or not this can be regarded

as actually transmitted by germ plasm is a question. It is significant that

in his family history a number of instances of so-called psychopathic

28] THE PSYCHONEUROSES 837

trends occurred somewhat more frequently than in the case of the average

individual. I should prefer to regard these personality traits as more

properly constitutional in the sense of characteristics which were either

inherited or acquired very early in life but in either case had become

more or less rigidly fixed so that they could not be affected to any great

extent by further cultural impact. In addition to this constitutional

foundation, however, and much more important both in the formation of

the symptoms and in the influence which analytic treatment could exert

upon them, we have a series of experiences running through his whole

early history which have made him the arena of conflicting emotional

tendencies. His natural desire for freedom and for the supremacy of his

sex was counterbalanced by the feeling of respect toward and depend-

ence upon the mother. We see in the subsequent development that with

all his apparent determination to retain his independence, he finally suc-

cumbed to the tendency to reestablish the early protective environment

afforded by the mother as soon as he met the person with whom he fell

in love and who represented most clearly the mother image. A similar

conflicting issue was the one introduced in his early adolescence when

liis growing need for heterosexual contacts clashed with his original de-

termination not to get married. Before this, when the need for such

contact was not biologically as strong, he could hold to his determination

with much less difficulty.

Other opposing trends somewhat less obvious may nevertheless be

considered as possibilities ; for example, the unconscious desire to enjoy

once more the protective and guiding hand of the mother introduced the

need of identifying his wife with the mother and thus placing himself in

a position of incestuous relationship with all the feelings of guilt and fear

of punishment that it usually involves. It is interesting to note that his

avenue of escape in the form of functional blindness reenacted the age-

old story of Oedipus, who paid with his eyesight for the unnatural act

of marrying his mother. It might be added here that an indirect investi-

gation proved conclusively that, at least consciously, this man knew

nothing of the myth of Oedipus Rex. Finally, we had in the events

immediately preceding the development of the disease the reenactment

of the early home situation. It is true that, superficially, early in the

analysis the patient came to regard the pregnancy and the birth of the

child as simply a stronger bond in the marital situation and, therefore,

removing the possibility of his regaining his freedom. Later on, how-

ever, it became evident that of greater importance was the fact that the

birth of the child was a living proof before the world of his having

assumed the role of his own father in relationship to a woman whom he

had identified with his mother. We also see that it was by his own

maneuvering that he had forced his wife into a position where she had

to act toward him in the same way that his mother had done toward his

father.

To recapitulate, therefore, etiologically we find the following three

essential features: (a) a certain type of personality which serves as a

838 PERSONALITY AND THE BEHAVIOR DISORDERS [28

foundation or suitable soil for the development of this form of reaction ;

(b) a series of life experiences leading to conflicting tendencies out of

which the person himself sees no solution; and (c) a reenactment of the

original setting which, given an opportunity, finds a solution in the patho-

logical symptom complex. These three features can be found to serve as

etiologic factors in the development of psychoneuroses, with this proviso,

however, that the development of the disease syndrome depends upon the

relative severity of each of these factors. Given a strong personality pre-

disposition, the other two factors need not be much more marked than

we find in the lives of normal people. Similarly, given a severe conflict,

the personality and reenactment of the situation need not be definitely

unusual ; and finally, given a reenactment of a particularly severe type,

the first two factors may be of a degree which in all probability would

not in themselves have led to the development of a psychoneurosis. This

is particularly apparent in the cases of the development of such disturb-

ances in situations as trying as, for instance, one finds in war.

Clinical Manifestations. Outstanding in the clinical picture of this

case is the creation of a somatic symptom without any basis in the form

of physical pathology in the organ involved. Moreover, we find a certain

characteristic affective attitude toward the symptom. At no time during

his blindness did this man show any great distress over his condition

and, in fact, from the beginning was more concerned about the future of

his family than his own. It is the lack of proper concern over symptoms

that has traditionally been referred to as "la belle indifference" of the

hysterical patient. It seemed as if he had excluded his eyesight from the

sphere of his personality and treated it in a more or less academic, ob-

jective fashion. This is a characteristic combination of features in one

particular form of psychoneurosis. A general survey of the field indi-

cates a variety of other possible clinical pictures which fall into three

main categories.

CONVERSIONS. By this we mean the transformation, as it were, of a

psychic conflict into a somatic symptom, and here we have several pos-

sible configurations: (1) the creation of physical symptoms without

underlying organic pathology; (2) exaggeration of organic symptoms or

their persistence when the cause no longer exists; (3) production of

organic pathology such as hypertension, mucous colitis, etc. ; (4) creation

of pseudo-psychotic symptoms.

ANANKASTIC REACTIONS. That is, ideas or activities which the

patient feels himself forced to entertain against his own will. Here we

have (1) obsessions, which are anankastic thoughts; (2) phobias, which

are unwarranted fears; (3) compulsions, which are forced activities such

as continuous uncalled-for hand washing.

FAULTY CONTROL OF EMERGENCY REACTIONS. This is a concept

used by Rado (1939) and has reference to the unwarranted utilization

28] THE PSYCHONEUROSES 839

of measures that biologically are intended to serve only in actual emer-

gencies. Anxiety, fatigue, sense of guilt or of inadequacy, and irritability

when they develop in situations that do not warrant their occurrence

belong to this group of symptoms.

We shall return in the following pages to a discussion of the various

forms of manifestations that can be grouped under each of these general

headings. At present we might say that all of these could be regarded as

features characteristic of the psychoneurotic picture or, in other words,

positive phenomena.

Differentiating Features. These are symptoms which are charac-

teristically absent in the psychoneurosis and whose presence would mili-

tate against such a diagnosis. We designate them as negative phenomena

and, unlike the positive features, they must all be absent in a given case

if it is to be regarded as psychoneurotic. They are as follows :

1. Demonstrable organic pathology relevant to the etiology of the

symptoms. This does not mean that a psychoneurotic patient may not

have organic disease of one kind or another. If the disturbance, how-

ever, is to be regarded as psychoneurotic, as, for instance, the blindness

in the case quoted above, there should be no demonstrable lesion any-

where in the visual apparatus which could be regarded as an adequate

basis for the symptom.

2. Consistent and lasting deterioration in the intellectual functions,

such as, for example, disturbance in orientation, judgment, memory, etc.,

as they are found in the psychoses.

3. Primary disturbances of the mood or affect as they are found in the

manic-depressive and schizophrenic psychosis respectively ; and finally,

4. Persistent distortion of external reality, such as projections.

On the basis of the above analysis we can now present a definition of

the psychoneuroses as follows : psychoneurotic reactions are disturbances

in the function of the personality which usually develop in certain types

of personality make-up, and are the expressions of emotional conflicts

whose nature or relationship to the symptoms are not consciously under-

stood by the patient. They are characterized by clinical features of a

positive type (conversions, anankastic reactions, or faulty control of

emergency measures) and negative features consisting of the absence of

relevant organic pathology, deterioration of intelligence, primary disturb-

ance of mood or affect, and consistent and lasting distortions of external

reality.

With the above definition and its analysis as a background, we shall

now attempt a more detailed discussion of the manner of development

and nature of the psychoneuroses. This discussion is to be presented in

three sections along the lines that were followed in the analysis of the

definition, that is: (1) etiology] (2) symptomatology and clinical syn-

dromes] (3) the differentiation of the psychoneuroses from other forms

of personality disturbances.

840 PERSONALITY AND THE BEHAVIOR DISORDERS [28

Etiology

As was pointed out above, the determining factors of the case pre-

sented could be arbitrarily divided into constitutional, developmental (in

terms of the formation of the conflict), and the immediate precipitating

factors in which, usually, a reenactment and accentuation of the conflict

situation takes place. These three sets of determinants are found in all

the cases, although it must be emphasized that their relative importance

differs in the individual cases so that first one and then another may be

brought into the foreground as the deciding etiological factor. In any

case, however, if the treatment is to be carried out in a rational manner,

due consideration must be given to all three. With this in mind, let us

see what role each one of these is likely to play in the causation of these

disturbances.

Constitutional. The use of the word constitutional rather than

hereditary is purposeful because we are interested primarily in person-

ality traits which either by virtue of hereditary transmission or strong

influence early in life become so deeply rooted in the make-up of the

individual that they are not easily influenced by environmental factors

either during the later development or the attempts at treatment. Fur-

thermore, it is an almost impossible task to differentiate personality

traits which are inherited from those which have been acquired early in

life. With our present available means of investigation we depend upon

historical data in the estimation even of the hereditary factors, basing

this entirely on the frequency with which they recur in the family history

of the individual. It is obvious, however, that since the early and most

impressionable years of the patient's life are spent in the closest prox-

imity with and dependence upon various members of the family, they can

just as easily be acquired as inherited. It is best, therefore, to speak of

them in a general way as constitutional and to take as criteria of their

belonging to this category the following: the presence of similar traits

in a comparatively large number of the family antecedents, their con-

sistent manifestation from the earliest days of life and throughout the

whole history of the individual, and the appearance of traits of this type

under conditions which, in the average person, would not lead to such

behavior. 1 Two such sets of characteristics are of importance in the

development of the psychoneuroses, that is, general constitutional types

and special character traits.

In the first case we deal with a general type of psychobiologic

make-up. It has long been recognized that human beings in general,

but particularly those in whom mental diseases develop, tend to fall into

special groups of mental and physical make-up which, as far as we can

see, are constitutional in nature and act as suitable soil for the develop-

1 It is to be emphasized that this concept of "constitution" is at variance with

that of other authors. One of the clearest statements of this controversy is given

in W. H. Sheldon's Chapter 18 in this book.

28] THE PSYCHONEUROSES 841

ment of personality problems. In the field of the physical types we find

the most systematic presentation in the work of Ernest Kretschmer, who

described a series of such categories ( 1921 ) . Thus we have the leptosome

with the thin, short torso, narrow shoulders, flat chest, long limbs, and

inverted, egg-shaped head. Contrasted to this is the short, pudgy, round-

headed, paunch-bellied, heavy- jowled, and short-limbed pyknic, and

finally, the coarsely-muscled and boned, broad-shouldered, narrow-hipped,

and square- jawed athletic type. Occasionally we find people who present

combinations of the athletic with either of the other two and we speak

of these as the mixed types. In rare instances we meet with various dys-

plasias such as dwarfs, giants, eunuchoid men, or masculine women,

which are spoken of as dysplastics. Kretschmer's own studies and those

of other workers in this field have led to the conclusion that certain

behavior characteristics are frequently associated with the physical type,

especially in people who represent the extremes of these types. The

familiar descriptions of the extrovert-introvert dichotomy and the closely

associated cyclothymic and schizothymic types occur most frequently in

relationship to the pyknic and leptosome physical make-up respectively.

There is no question but that where the two occur together, predisposi-

tions toward certain forms of reactions are frequently found. Thus we

find that the introspective, brooding, rationalizing behavior with its

tendency to daydreaming, egocentricity, and the development of fan-

tastic and impractical forms of behavior is most usually found in persons

who are constitutionally of the leptosome and introverted type of make-up.

On the other hand, we find that the easy-going, suggestible, anaklitic per-

son who continually plays up to the gallery and dramatizes his reactions

is most likely to be constitutionally of the pyknic and extraverted

make-up. It is easy to see that in the choice of symptom formation in

the psychoneurotic reaction, these constitutional characteristics must play

a definite role. Furthermore, the ease with which an abnormal person-

ality reaction is assumed when one is faced with a difficult situation will

also be definitely influenced by such constitutional predispositions. It

must be pointed out, however, that a large number of people who present

these characteristics, even in extreme fashion, need not necessarily de-

velop psychoneurosis unless other factors come into play. 2

Still more important in this connection are the special constitutional

factors which we find in certain people. They actually seem to dispose

the person toward the development of certain psychoneurotic manifes-

tations. Thus we have the individuals who, throughout their lives, have

been known to be pathologically sensitive. From their very earliest days

they exhibit special susceptibility to any kind of emotionally colored

stimuli. They suffer under ridicule, always seek for reassurance, react

in an exaggerated fashion to success and failure, and distort statements

made to or about them. We can easily see how such a person may go on

2 One of the most impressive and systematic presentations on this subject is the

recent work by W. H. Sheldon (1940).

842 PERSONALITY AND THE BEHAVIOR DISORDERS [28

to develop feelings of inferiority and suspiciousness, anticipations of in-

justice and retaliations, and so on. Another form of pathologic constitu-

tional trait is found in the chronic complainer. From early childhood, he

exaggerates physical symptoms and continually lives under the fear of

developing some disease. The careless suggestion by an outsider of the

presence of some physical anomaly may serve as the nucleus for the

development of an ever-widening set of symptoms whether or not any

physical basis exists. A third commonly encountered characteristic of

this type is the so-called obsessive form of reaction. Here we find indi-

viduals, unusually scrupulous and pedantic, who tend to analyze even

trivial occurrences in the most minute fashion. They tend to dwell with

remarkable tenacity on thoughts which come into their minds and if

these thoughts are related to some actual or imagined danger, they may

gradually turn into true obsessions from which the person cannot free

himself.

In evaluating the true nature of these constitutional characteristics it is

well to remember that no matter how deeply rooted any one of them may

appear to be, they are nevertheless likely to have been caused by faulty

development (see Chapter 20 by Ribble). This is especially frequently

seen in the cases showing deviations in their sexual life. Emphasis has

been placed here on the fact that homosexuals, for instance, are charac-

terized by such features as effieminacy in the male and masculine man-

nerisms or even physique in the female. One could argue, however, that

even these may be developed on the basis of early conditioning or

identification.

Developmental Determining Factors. The effect of developmental

influences upon behavior and their importance in the causation of abnor-

mal reactions is too complex a subject to present fully in a short discus-

sion of this type. The literature is replete with theories and observa-

tions which must be digested fully before one can abstract that which is

pertinent to the subject. The reader will be well advised to refer to

these, some of the more important of which are given in the bibliography.

Since other chapters in this book will deal more fully with some of the

special phases of this subject (see Parts IV and V), the following dis-

cussion will be limited to a general resume and will not venture into the

more controversial and speculative aspects of it.

The process of development starts out with a certain number of given

factors as a foundation. On the one hand we have the basic biological

needs or instincts of the individual as an organism and those potential-

ities which we have discussed under the headings of constitutional char-

acteristics. On the other we have the environmental setting into which

the individual is born. Development as a dynamic process will have as

its goal the proper adjustment of these two sets of factors at any given

time to the changes that take place in both of them throughout the

course of time. It is logical to assume that at first the individual recog-

nizes no needs other than those that emanate from himself, and it is only

28] THE PSYCHONEUROSES 843

through his contact with the outside that he begins to establish patterns

of behavior in relationship to it. The nature of these patterns will depend

primarily upon the fact that environmental factors differ in regard to

their relationship to the individual. Thus some of them become the basis

for inhibition or prevention. Others, by virtue of their assistance in the

gratification of instinctive needs, will be considered as beneficial and pro-

tective and characteristic of persons to be emulated because of their

ability to do things which the individual himself desires to do, and will

serve as objects of imitation, as models for the development of ideals.

At the same time the individual undergoes changes by virtue of his

potentialities as a growing person. Changes take place in his size, shape,

features, in the functions of his endocrine glands, etc. Conditions which

are acceptable at one stage during this process of development become

obsolete at another stage, and are displaced by new needs and new forms

of behavior. Thus, a component develops in the personality which has to

deal on the one hand with the relationship of the individual to the en-

vironment as a whole, and to himself as a changing organism on the

other. This component assumes a special relationship to his primitive

needs, sanctioning them at one time and preventing their free flow toward

gratification at another. In the course of this development minor clashes

occur throughout one's existence, but at certain times the conflicting

tendencies are in particularly strong opposition and greater difficulties

in adjustment will occur. It is at those points that the foundations of the

psychoneuroses are most likely to be laid.

It must be remembered also that the forces which run counter to in-

stinctive needs exert pressure upon the individual not only at the time

of their original occurrence, but if repeated may establish patterns which

will lead to conflicts even where the original setting is not present.

Various forms and combinations of such influences are possible. In the

first place we must consider the effect of faulty conditioning. A person

who has been repeatedly subjected to the simultaneous effect of two

opposing trends in his early childhood will, in his later life, when one

comes to the surface, react to the situation as though both were present.

Thus, for instance, a child who has had repeated frightening or disgust-

ing experiences in relation to eating some special food may later experi-

ence feelings of anxiety or disgust whenever the food alone is presented.

This is particularly important in relationship to the social taboo that is

attached to sexual activities in the childhood of a great many individuals.

Another factor of importance, particularly in relationship to the develop-

ment of the psychosexual life but also true in other phases of behavior,

is that which develops in conjunction with changes occurring with

growth. At any stage during the growth of the individual, objectives

and ways of gratification of instinctive needs may be experienced as satis-

factory and socially approved but at another stage will have to be radi-

cally changed. This requires an emancipation from a form of behavior

which has become deeply rooted both by virtue of personal gratification

and approval by society. It is difficult enough, even in the normal mdi-

844 PERSONALITY AND THE BEHAVIOR DISORDERS [28

vidual, to have to break this routine and adjust himself to new forms

of behavior. The success of accomplishing such a change will naturally

depend upon two factors, that is, the strength of attachment to the

original pattern and the force of attraction of the new one. If, because

of accidental or purposeful occurrences, either one of these is affected,

this change may be rendered either more easy or more difficult. Thus,

for instance, the child who in his early years is overprotected by the

home environment and is then called upon to adapt himself to an inde-

pendent existence at school may find it difficult to emancipate himself

from the constant need of the affection and care of the home. If such a

child, in addition, happens to have the misfortune of attending a school

where conditions are particularly difficult for adjustment, his ability to

emancipate himself may be rendered impossible and in the search for a

solution, pathological means of solving the problem may develop. The

actual choice of the manner of escape may be accidental or suggested by

definite patterns. If the child, for instance, has on previous occasions

learned that physical disease can be used as a means of securing extra

sympathy and protection, he may adopt that. Or if a pattern at home has

been established wherein some member of the family utilizes a certain

form of escape in difficult situations, that may present itself as a possi-

bility. The most commonly occurring examples of this type of reaction

are to be found in the psychosexual life, first because in our form of

social organization it is likely to be burdened with more taboos and social

restrictions than any other phase of behavior and secondly because it is

in this field that the most drastic changes take place in the development

of the individual himself.

Other possibilities for the development of such reactions must be con-

sidered. A great deal of emphasis has been placed on the importance o!

feelings of inferiority developed in early life in relation to some actual

or imagined physical or mental inadequacy. In his search for compensa-

tion for this inferiority a person may attempt to excel in some other

aspect of his activities and if that is impossible may develop neurotic

manifestations as a means of securing sympathy or superiority. A similar

mechanism may be observed as a result of indirect effects of organic dis-

eases. The child who, early in life, has suffered an attack of a disease

process such as infantile paralysis and has been left with some obvious

physical defect will have to go through life with the feeling that he is

not only different from but also inferior to others. He will not be able

to have the normal outlets and pleasures that sports and games afford

and may even feel himself discriminated against or disliked by the rest

of the group. He will become sensitive, insecure, and will naturally

search for other means of gaining the limelight to a point where this

may come to be his sole interest in life.

So much for a discussion of the general and more obvious possibilities

in regard to developmental factors. In the fields of instinctive organiza-

tion and social adjustment a large number of more complex relation-

ships are encountered and for a discussion of these we refer the reader

28] THE PSYCHONEUROSES 845

to the chapters dealing particularly with the psychoanalytic concepts and

the influence of social impacts upon the development of personality

functions.

SITUATIONAL FACTORS. In the case used in our definition it was seen

that the actual development of the abnormal behavior came in relation-

ship to a special situation, that is, the patient's marriage and the birth of

the child, and that the symptoms served as a method of escape from this

particular situation. It is true that had there not been a special per-

sonality background and specific conflicts established in the early life of

the patient, the precipitating situation probably would not have caused

any further strain on the adjustment than is usual in such circumstances.

It can be argued just as well, however, that had the patient not married

this particular type of person, and had pregnancy and the birth of a child

not taken place or even had there been no collision in which he was in-

volved, the particular symptom complex would not have come about.

Neither of these two arguments is justified any more than the arguments

offered in the age-old controversy concerning the relative importance of

constitution and environment. The causes of the psychoneuroses must

always be looked for in a constellation of circumstances rather than in

any one single factor. It is true, however, that a certain relationship must

exist between all these factors if they are to converge upon some particu-

lar form of behavior at a given time. Thus it is that given a certain

weakness in the personality it can serve as suitable soil for a particular

type of emotional conflict developed in early life. Similarly, given a

combination of these two it will take a special form of immediate strain

that will lead to the appearance of symptoms. In some cases it may be

some social upheaval, such as war, in other cases threatened loss of eco-

nomic security, in still others some physical disease. All of these factors

may be described as situational determining factors. It is obvious that

they can be of infinite variety just as all possible experiences in life are

of infinite variety, but for purposes of practical approach we can arbi-

trarily reduce them to several main classes.

SOCIAL FACTORS. In the discussion of the development of the indi-

vidual it was emphasized that patterns of behavior develop during the

life of the individual in relationship to the group in which he lives. He

must learn to take into consideration the established standards and de-

mands of the group and to a certain extent fit his own needs to these.

While certain needs may be allowed gratification, others must be in-

hibited or delayed. In a stable social situation in adult life the indi-

vidual, if he adjusts, will have established certain standards to which he

can adhere, and from which he need deviate only within very narrow

limits depending upon minor changes. With the appearance of more

critical upheavals in the group these standards of behavior may have to

be radically changed and then the ability of the person to adjust is pro-

portionately taxed. We need only mention the strain upon adjustment

which has come about from the various sociological disturbances that

846 PERSONALITY AND THE BEHAVIOR DISORDERS [28

have developed in the last few years. The rapid changes in political and

economic situations in Europe or even in this country have taken their

toll in failures in adjustment of a large number of people. It is true that

not all of them developed neuroses. Given a robust personality and an

adequate development it is surprising and gratifying to see how flexible

the adjustment of a human being to the most radical changes in estab-

lished social organization can be, but there will always be a certain num-

ber who will succumb to the final situational disturbance.

The nature of the change need not be one that involves a whole

group, but may be one that develops in the life of the particular person.

Immigrants, for instance, who find themselves forced to adjust to strange

standards and forms of behavior may find difficulty in making the transi-

tion, and similarly people who change their milieu within the same group

by moving from a rural to an urban community, from agricultural to in-

dustrial forms of life, and so on. Within the family itself there are

numerous possibilities of this type. The child who has been brought up

in a family where certain relationships between the various members

exist may find it difficult to orient himself after marriage if forced into a

new type of environment. The everyday relationships of husband and

wife, of child and parent, even forms of food or dress may produce a

constant state of irritation which can lead to a gradual development of

psychoneurotic reactions. Religious differences, gaps in ideologies, edu-

cation, and various other interests may cause similar strain on the ability

to adjust. All of these are much more important than one may be led

to believe by those who tend to minimize the importance of precipitating

factors and place the main emphasis on the earlier experiences as per-

sonality foundations. The fact remains, however, that even in practical

therapeutic work we find that social difficulties of this type, if they

can be removed, will frequently in themselves help in alleviating the

symptoms.

ECONOMIC FACTORS. The stress and strain of the struggle for exist-

ence which has become particularly acute in modern life, where security

so often is expressed in terms of the quantity and quality of worldly

possessions, must be regarded as another important group of possible

situational factors. Economic disasters either of the type that affects the

whole group or only the particular individual, loss of home or material

possessions especially if it is sudden in its development may, in certain

individuals, be the determining factor in causing a breakdown. Here, of

course, as in the case of the other forms of precipitating conditions, the

availability of other assets is of great importance. Of deciding influence

are such circumstances as the socially acceptable values, possible forms of

compensation, the breadth and diversity of interests, the age of the indi-

vidual and his resilience, etc.

PERSONAL FACTORS. It was emphasized above that the changes in

the individual himself that occur with the passing of years, although they

are of a continually progressive type, nevertheless present at certain

28] THE PSYCHONEUROSES 847

stages more drastic transitions than at others. Whether it is because

of social tradition or because of biological development, they mark critical

periods in the life of the individual and are known to be particularly

vulnerable spots in the development of mental diseases. Such is, for

instance, the critical period that confronts the child when he is more or

less suddenly forced out of the protective environment of the family

into the competitive life at school. Another stage of even greater critical

stress is that of puberty, with its implications both social and biological.

The rapid development of endocrine and other physical changes intro-

duces new needs and a change in objectives of instinctive urges, and at

the same time the person is socially expected to act as an adult in con-

trast to the privileges and patterns of behavior of the child. Marriage

and the introduction of new responsibilities and the need to adjust to an

almost totally different mode of life as may be true in some cases is

another example of this form of drastic change. Finally, there is the

impending change that looms with such great importance in the life of

most individuals at the involutional period. The necessity of giving up

activities and interests which in the case of some people have become the

only ones that matter, the need to resign oneself to what may be re-

garded as an unproductive, and at times dependent, old age is quite fre-

quently one of the most important causes in the development of a serious

personality disturbance.

ORGANIC FACTORS. In discussing the definition of the neuroses, it

was emphasized that one of the distinctive features of these syndromes is

the fact that they do not show etiologically relevant organic pathology.

To what extent an organic disease may in itself by a breaking down of

tissues lead to development of neurosis is not definitely known, and is

considered by a great many as unlikely. It is true, however, that in an

indirect way somatic disease may serve as a definite situational factor.

It must be remembered that from a psychological point of view a disease

process, aside from its organic effects, must be considered as an occur-

rence of great importance in the life of the individual, and the adjustment

to it will depend materially upon the extent to which it renders the in-

dividual uncomfortable, endangers his feeling of security, and jeopardizes

his subsequent ability to function at the original level. In addition to this,

certain aspects of diseases and their social significance play an important

role. Feelings of guilt and shame that accompany certain diseases, social

isolation, traditional attitude of hopelessness as, for instance, in the case

of tuberculosis or cancer, and other psychological factors may result in

reactions altogether out of keeping with the actual severity of the disease.

Clinical Manifestations

The presentation of the clinical manifestations of the psychoneuroses

with the full range of deviations from normal behavior and experience

that can be encountered in this field is a difficult task in the limits of a

short discussion. There is hardly any function, physiological or psycho-

848 PERSONALITY AND THE BEHAVIOR DISORDERS [28

logical, that may not be the site of some one or another psychoneurotic

symptom. Here we must confine ourselves to a brief description of some

of the more familiar and striking symptoms with the hope that those

who are interested in a more detailed study will seek this information in

available texts, some of which will be indicated in the bibliography. It is

proposed to present these symptoms under the headings of the subdivi-

sions presented in our definition and designated as "positive" features.

At the same time we shall attempt to gather these symptoms under the

groupings of their clinical manifestations, utilizing the terminology ac-

cepted by psychiatric textbooks. This will be especially convenient

since to a large extent the major diagnostic entities correspond with the

subdivisions that were described in the definition. With this in mind, let

us first consider the various phenomena which can be grouped under

the subdivision of the conversions, and which are usually included under

the clinical entity of the hysterias.

The Hysterias (Conversion Neuroses). In the case used in our

definition we found in the center of the clinical picture the symptom of

complete blindness which, on the one hand, seemed not to be based on

organic pathology and, on the other, served the purpose of offering an

escape mechanism to a person who was faced with an apparently in-

soluble problem. This can serve as a typical example of a conversion,

whereby we mean the transformation of an emotional conflict into some

specific symptom, somatic or mental. Four different types of conversions,

all of them representing different forms of hysterical reactions, can be

generally recognized. They are as follows :

1. The creation of physical symptoms where no signs of organic

pathology can be found. We meet here a most astounding variation of

manifestations and it can be safely said that there is hardly a somatic

function anywhere in the organism that does not in some case or another

serve the purpose of these conversions. The most commonly involved

are first of all the various sensory functions : blindness, deafness, disturb-

ance of the sense of pain and other representatives of common sensation,

disturbance of sense of smell, etc. The disturbance may be one of com-

plete loss of sensation, such as, for instance, in the cases of hysterical

analgesia where a pin can be stuck right through the tissues without

causing any apparent experience of pain, or the case of complete blind-

ness described in our illustration. There may, however, be simply a

diminution or restriction of the function of the particular sense organ

such as hypesthesia, hypalgesia, concentric restriction of the field of

vision, diminution of hearing, etc. Finally, these conversion symptoms

may manifest themselves in an increased sensory impression such as is

shown in some of the painful paresthesias or hyperalgesias. Motor func-

tion also may be disturbed. Loss of ability to produce sounds (aphonia),

paralyses or pareses of voluntary movements of the arms or legs, diffi-

culties in breathing, retention of urine with an apparently decreased tone

of the bladder often occur. Here, too, the loss need not be complete. One

28] THE PSYCHONEUROSES 849

may find hoarseness or whispering instead of aphonia, or simply a re-

striction of the scope of movement of voluntary musculature rather than

complete paralysis. Occasionally we may have the development of dys-

kinesias (distortion of movement) of various types, such as tremors of

various parts of the body, dystonias, tics, choreiform movements, and

sometimes generalized convulsions following the special patterns that

have been so frequently described under the name of major hysteria.

Painful sensations of various types are quite frequent as conversion

manifestations. Headache, precordial pain, abdominal distress, arthritic

pains, backache, and coccydynia are among the most common. Visceral

manifestations such as persistent vomiting, incontinence of urine, painful

or disturbed menstruation, dysfunctions of the sexual activities such as

impotence or frigidity, disturbance of gastro-intestinal functions, and

many others are also frequently found.

In all of these it is important to appreciate that we are dealing here

with expressions not of recognizable organic systems but of their psycho-

logical representations. By this we mean that in the case of loss of

sensation in the limbs we get such symptoms as glove-and-stocking

anaesthesia. This would mean that the hand or foot is affected rather

than an area of the body supplied by some particular nerve or center, and

similarity with visual disturbances, where we get such things as double

vision that persists even when one eye is covered, or a telescopic con-

striction of the field. This is an important consideration not only in the

recognition of the symptom as such with its psychological basis but also

in the differentiation of these symptoms from organic disease.

2. Exaggeration of organic symptoms or their persistence when the

cause no longer exists. Here we deal with conditions where organic dis-

ease is present or has existed at some time in the past, but the symptoms

are unconsciously exploited either beyond their scope and intensity or

after the organic basis for them has ceased to exist. They are encoun-

tered especially in the so-called industrial, war, insurance, and traumatic

neuroses. Sometimes it is difficult to differentiate them from pure ma-

lingering, to which reference will be made further on. They differ from

the group described above in that by their nature they are much more

likely to follow actual anatomical distribution. Into this group also falls

the common tendency to exaggerate normal sensations or discomforts

produced by the heart-beat, gastro-intestinal motility, noises in the ear,

and other physiological functions.

3. Production of organic pathology. It is a well-known fact that emo-

tional experiences are almost always accompanied by changes in some

of the physiological functions. Pulse and blood pressure fluctuations,

mobilization of blood sugar, constriction or dilation of blood vessels,

changes in the function of the adrenal and other glands, gastro-intestinal

motility, etc., can be shown to undergo demonstrable organic changes.

It is logical to expect, therefore, that, depending upon the intensity or

duration of a given set of emotional experiences, definite and sometimes

irreversible pathology may occur. During the last few vears a great deal

8 5 o PERSONALITY AND THE BEHAVIOR DISORDERS [28

of work has been done in this field, and today it forms a large portion

of the field of psychosomatic medicine. Our reference to these will be

very brief since another chapter in this book deals with them more exten-

sively. They are of particular importance since the functions affected in

this way may be of vital importance and of such intensity as to interfere

seriously with the health of the individual. Skin lesions, often of a severe

type and showing stubborn resistance to somatic treatment, are frequent.

Disturbances of the respiratory apparatus, allergic reactions of various

types, and dysfunctions of menstruation often develop on the basis of

psychoneurotic mechanisms and can be treated accordingly. Hyperten-

sion with various disturbances of the circulatory system and kidney func-

tion form a special chapter in this subject. A great deal of work has been

done on the occurrence of pathological conditions in the gastro-intestinal

tract which find their origin in emotional conflicts. Gastric ulcers,

mucous colitis, spasms of the sphincters in this tract are a few of the

important types of lesions that have been discussed under this heading.

The subject is still in its early stages of development and speculation

perhaps goes beyond actually known facts at times. It has even been

suggested by some that such well-known diseases as multiple sclerosis,

nephritis, and even some new growths may be largely dependent upon

psychoneurotic mechanisms. It must be emphasized that we must pro-

ceed very cautiously in this not yet clearly defined subject, but its

importance both from a theoretical and therapeutic point of view has

perhaps not been fully realized.

4. Creation of pseudo-psychotic symptoms. Conversion manifesta-

tions may find their expression not only in symptoms referable to somatic

functions but also in the form of mental disturbances more or less similar

to those found in the more serious personality disturbances known as the

psychoses. The hysterical amnesias belong to this group. They may

cover periods of time lasting only a few moments or may produce gaps

of a longer duration sometimes even to the extent of blotting out the indi-

vidual's whole past life. They may be complete or may permit the

patient patchy memories of isolated events. They may have reference to

periods during which the patient behaved normally or they may erase

events of a pathological nature such as a delirious condition or convul-

sions. Other reactions of this type are the hysterical "twilight states"

during which the patient may appear partially confused or dazed, dream-

states, stupors, fugues, etc. Most of these are characterized by dramatic

and fantastic performances. The patients apparently believe themselves

transported into a magic world in which they see wonderful visions, hear

heavenly music, or are terrified by blood-curdling monsters. In the

course of some of these states the patient can be found to live out an

accentuated drama of an unfulfilled wish or to regain the possession of a

lost love-object. It is during these states that the hysterical patient

may manifest hallucinatory or delusional experiences which more closely

resemble a dream experience than do those that we find in the

psychoses.

2 8] THE PSYCHONEUROSES 851

Psychasthenlas ( Anankastic Reactions) . In this group are placed

forms of psychoneurotic reactions which, although different in many

respects, have in common the fact that the patients feel themselves com-

pelled by some inner force and against their own will or reason to think,

act, or feel in an abnormal manner. Three major forms of symptoms are

found here.

OBSESSIVE THINKING. The characteristic feature of this symptom is

the recurrence of undesired and discomforting thoughts of which the

patient is unable to rid himself even if he is quite able to understand their

illogical nature and protests constantly his innocence of wishing to en-

tertain such thoughts. The religious person who is continually tormented

by sacrilegious thoughts and who may, to his great consternation, even

feel himself forced to make blasphemous statements ; the woman who

experiences thoughts related to injuring her husband or children; men

who continually fight against thoughts of homosexual activities, all fall

into this category. The development is usually gradual, frequently be-

ginning with occasional ruminations which can at first be easily dismissed

from the mind, but even then accompanied by anxiety lest these thoughts

may become more deeply rooted and may actually lead to abnormal,

asocial, or immoral acts. Unlike the hysterical symptoms, they are often

accompanied by marked depressive emotional reactions, the person mak-

ing determined efforts to displace them, and the more he does so the

greater is the stubbornness with which they return to his mind. It is a

well-known fact that as a rule the danger of persons actually carrying

out these thoughts is minimal if it ever occurs, although the mere fact

that the thoughts cannot be gotten rid of may occasionally lead to des-

perate measures, sometimes even suicide. Very often a great many ritual-

istic activities are undertaken to deal with these thoughts; peculiar

movements such as tics, stamping of feet, stereotyped gestures, etc., may

develop in order to counteract the thoughts.

PHOBIAS. These are unwarranted fears which, much like the obses-

sions, the person feels himself forced to experience although he con-

sciously recognizes the fact that no actual danger exists. A large variety

of these have been described and various Greek names applied to them.

A few of the more common ones include claustrophobia, the fear of con-

fined spaces; agoraphobia, the fear of open spaces; aichmo phobia, the

fear of sharp objects ; mysophobia, the fear of contamination, and nu-

merous others. The distinguishing feature of these fears as contrasted,

for instance, with the delusional fears of the psychotic is the fact that

the person realizes that these fears are born within himself. They can

prove definitely incapacitating, however, as, for example, in the case of

a person with a claustrophobia who will not enter a small room or narrow

passage even when it is essential to do so. Even when threatened by

danger, his phobia may prevent him from saving himself by taking refuge

in a small but safe place. Phobias are frequently complicated by obses-

sive thoughts so that the patient thinks constantly of the particular object

852 PERSONALITY AND THE BEHAVIOR DISORDERS [28

of his phobia and experiences as much discomfort as when he is faced

with the actual fear-stimulus.

COMPULSIVE ACTS. These are forms of behavior which the person

carries out consciously either without knowing the reason for such

activity or for reasons which he knows have no logical foundation. One

of the most common of these is the so-called "hand washing" compul-

sion. The individual realizes only that he is being compelled by some

inner force to wash and scrub his hands continuously although he admits

quite freely that there cannot be any dirt or contamination on them.

This often goes with a mysophobia, the person expressing the fear of

possible danger of infection to himself or of carrying it to other people.

Attempts to avoid touching possible sources of contamination usually

accompany it. Objects are handled by using gloves, clothing, or other

coverings, or the person becomes quite skilful in opening doors with his

elbows, moving objects by pushing them with parts of the body which

are covered by clothing, etc. Other examples of this form of behavior

are found in kleptomania, or the compulsion to steal ; pyromania, or the

compulsion to set fires ; poriomania, or the need of moving from place to

place. In a great many of these the person does not even attempt to

justify these acts, simply falling back on the excuse that he cannot help

himself.

Although in certain cases any one of the forms of psychasthenia de-

scribed above may occur as the single expression of the neurosis, they

more usually occur together and sometimes one develops as a sequel to

the other, such as the development of a hand washing compulsion be-

cause of the fear of contracting a disease. It is important to emphasize

the fact that one usually finds the psychasthenic syndrome developing in

a certain type of personality. Long before the actual outbreak of the

fully developed symptom we find these persons exhibiting such char-

acteristics as rigid pedantry, scrupulousness, tendency to hair-splitting,

stubbornness in their convictions, and so on. In a more general way the

personality make-up of such an individual is very likely to be that of the

introverted, self-centered, daydreaming type as contrasted with the sug-

gestible, extraverted, demonstrative person that is so frequent amongst

the hysterical patients. From a practical point of view it is important to

appreciate, furthermore, that such personality characteristics are more

frequent and more deeply rooted in the psychasthenics than in the other

neuroses and therefore present less favorable prognoses. Fortunately

these cases occur considerably less frequently than those described under

the hysterias.

Faulty Control of Emergency Reactions. The first two categories,

that is, the hysterias and psychasthenias, have been frequently referred

to in the literature as the true psychoneuroses, particularly since, in their

development, one usually finds the sequence of events described in our

sample case. By this is meant the development of the original conflict

in early life without any immediate symptoms, the latter manifesting

2 8] THE PSYCHONEUROSES 853

themselves in relationship to a reenactment of the original setting

(Freud, 1895). In the early psychoanalytic literature these reactions

were differentiated from what were called the "actual" neuroses in which

the symptoms were considered as primarily dependent upon an imme-

diate situation. 3 The clinical pictures described in this group corre-

sponded to the two syndromes known as "anxiety neuroses" and "neur-

asthenia." It has since been recognized that such a distinction is not

really a valid one but that early experiences in terms of the establish-

ment of conflicts are as important here as in the other forms (Mala-

mud, 1931). Therefore, in the present discussion, we shall assume that

whereas in general the etiologic mechanisms follow the same principles,

the type of clinical pictures presented is different.

As was suggested earlier in this chapter, the type of symptom forma-

tion that we find here can be best described as a faulty control of emer-

gency reactions (Rado, 1939). Biologically, the organism is capable of

responding with a certain mobilization of safety devices when it is faced

by an actual emergency. Thus when an animal is in danger, various

psychological and physical activities come into play. The emotional ex-

perience of fear is accompanied by changes in endocrine functions, blood

chemistry, circulatory reactions, respiration, etc. All of these may be

grouped under the general term of fear or anxiety. Similarly when mus-

cular exertion has reached a point where all the readily available energy

has been strained and reserve supplies must be tapped, the phenomenon

of fatigue develops. Such emergency measures are, of course, consid-

ered normal when they develop in relation to conditions which call for

them. If, however, anxiety should develop without an actually existing

danger, or fatigue be experienced without adequate exertion, then we

might speak of faulty emergency reactions.

ANXIETY NEUROSIS. Clinically, this disturbance expresses itself in

attacks of vague, unexplained but intense fear which, at least in the

beginning of the disease, does not seem to be attached to any particular

object. It can best be described as being near to a normal fear of a vital

danger, but is different from it in that no such danger is present and,

in most cases, not even imagined to be present. The concomitant symp-

toms are usually of the same kind as found in real fear a kind of para-

lyzed state of the musculature, cold shivers, a sense of pressure in the

head and precordial regions, profuse cold sweating, palpitation of the

heart, and at times relaxation of the sphincters. As time goes on the

attacks may be consciously associated with some of the concomitant

symptoms. The person may develop the fear that his heart may stop,

that something will burst in his head, or that some serious disease is

developing in his gastro-intestinal system. The concomitant symptoms

may also assume the controlling feature of the picture, and thus instead

of pure anxiety attacks we may have tachycardia, alternating constipa-

3 Systematic psychoanalytic accounts of the psychoneuroses are available in

Fenichel (1934) and Brown (1940).

854 PERSONALITY AND THE BEHAVIOR DISORDERS [28

tion or diarrhea, dizziness, or even vertigo, and others. It has been em-

phasized particularly in the early psychoanalytic literature (Freud, 1895),

that the most important etiologic factors of this form of neurosis are to

be looked for in some interference with normal sexual activities, such as

prolonged abstinence in the presence of constant stimulation as in pro-

tracted engagements, coitus interruptus, and so forth. It is true that

these factors are very commonly found in the immediate history of the

development of such conditions. It must be emphasized, however, that

in the background and serving as the basis for such reactions, one can

find mechanisms akin to those encountered in the forms described above.

This is a consideration which is of great practical importance in the

treatment of the anxiety neuroses.

NEURASTHENIA. This term has, more than any other, been misused

in its application to a great many conditions both organically and psy-

chogenically produced which in reality belong to other symptom com-

plexes. In its pure form it is characterized by feelings of physical and

mental inadequacy, complaints of fatigability without adequate exertion,

paresthesias in the back of the neck, and a sense of general weakness. In

the more chronic and severe forms of this disturbance the patients usually

describe themselves as mental and physical "wrecks/* They cannot con-

centrate on any activity, they wake up in the morning feeling exhausted,

"fagged out," unable to get started on any work. Increased irritability,

feeling of lack of sexual vigor at times amounting to impotence, and a

vague sense of anxiety may complicate the picture. In contradistinction

to the anxiety neuroses, these states are usually monotonously chronic

without any great degree of variation and as is too frequently the case

the patient seeks for help only after long duration of the symptoms.

Here we find, as in the psychasthenias, a premorbid personality whose

characteristics merge into the symptoms of the neurosis so gradually that

it is sometimes difficult to tell what is the original endowment of the

person and what are the symptoms of the disease. Because of this such

cases are often difficult to treat and the prognosis is frequently poor.

Delimitation and Relationship to Other Forms of Personality

Adjustment

In the definition it was emphasized that the psychoneuroses are char-

acterized not only by a certain set of symptoms peculiar to them but by

the absence of clinical features which belong to other forms of personality

maladjustments. This group of "negative" features can serve in out-

lining a differential diagnosis. The scope of the present discussion does

not permit an analysis of this aspect of the problem as complete as one

would find in a medical textbook. Other chapters of this book will

present discussions of a number of related personality disorders. It is

important, however, to emphasize not only the differentiation but also

the relationships of the psychoneuroses to these other forms of behavior,

28] THE PSYCHONEUROSES 855

since the manner of symptom formation of the psychoneuroses is one

which is closely related on the one hand to normal behavior and on the

other to that encountered in the psychoses and reactions to somatic dis-

ease. This means that in a large number of personality disturbances

which are found at the borderline between the psychoneuroses and these

other conditions we are apt to find symptom complexes that depend as

much on psychoneurotic mechanisms as they do on other determining

factors. From the point of view of treatment and management of these

problems, it is essential to understand to what extent the disturbance

depends upon the psychoneurotic mechanisms. We can then treat this

aspect of the disturbance psychotherapeutically and at the same time deal

with the other aspects of the disease on the basis of what we know about

its etiology. With this in mind let us consider some of the conditions

with which the psychoneuroses can be most easily confused.

Somatic Disease. Since the psychoneuroses, particularly the hys-

terias, tend to manifest themselves in the form of somatic complaints, the

differential diagnosis here has long been considered very difficult. An

adequate knowledge of medicine is obviously imperative in arriving at a

correct diagnosis. No one who is not equipped to make an adequate

physical examination and to recognize the existence of a physical disease

should undertake to make a final diagnosis in such conditions. Given

such a preparation, however, one should experience little difficulty with

clear-cut conditions. On the one hand, given a fundamental knowledge

of the pathognomonic symptoms of psychoneuroses, one realizes imme-

diately their difference from the somatic disease. On the other hand, the

various diagnostic aids and laboratory methods developed in medicine

should serve as reliable criteria for differentiation. Physical examination

of the heart and the electrocardiogram in the case of cardiac disease, tem-

perature rises, blood changes and bacteriological tests in the case of in-

fectious diseases, blood chemistry and examination of the urine in kidney

diseases, and many others should serve as dependable evidence of organic

etiology and should exclude purely psychogenic reactions. In the case

of organic disease of the nervous system we have already referred to the

fact that the psychoneurotic counterpart of an organic nervous ailment

such as paralyses, sensory changes, etc., does not follow the anatomical

distribution but the psychological idea of the part involved. Reference

has been made to such things as "glove and stocking" anaesthesia, con-

centric restriction of the field of vision, etc. It is conceivable, however,

that psychogenic mechanisms may be associated with or engrafted upon

an organic disease. In such cases, provided we realize the presence of

both, the treatment will have to be planned with due consideration of

both. Inasmuch as the maladjustment is psychoneurotic in nature, we

shall try to discover the reasons in terms of life experiences and correct

them. At the same time, however, we shall keep in mind the organic

factors and try to eliminate them if possible. Thus the psychological re-

action to and utilization of the symptoms of diabetes will have to be

856 PERSONALITY AND THE BEHAVIOR DISORDERS [28

attacked on the basis of the personality factors involved at the same time

that dietetic and medicinal therapy is instituted. One of the greatest

achievements of the workers in the field of psychosomatics has been the

recognition of such combinations, which has led to a more successful

form of treatment in the way of cooperation between the internal medi-

cal man and the psychiatrist. We cannot refrain from the temptation

of pointing out that in a great many of these conditions the organic dis-

ease at this stage of our progress in medicine is practically beyond any

successful therapeutic influence. On the other hand, the reeducative

and analytic approaches often succeed in ameliorating the maladjustment

materially in such patients.

The Psychoses. The differentiation of the psychoneuroses from the

so-called functional psychoses the manic-depressive, schizophrenic, and

paranoid groups (see Chapter 29 by Cameron) should not present any

great difficulties in the clear-cut cases. The primary mood disturbance

of the manic-depressive syndrome, the typical affect and association dis-

turbance of schizophrenia, and the reality distortion that characterizes

paranoid psychoses are features that should not be present in a case

definitely diagnosed as psychoneurotic. This is also true of clear-cut and

lasting intellectual deterioration. Here, too, however, we find borderline

conditions which seem to correspond to the nature and mechanisms of

both psychoneuroses and psychoses. It is well known that a great many

psychoses may begin with symptoms characteristic of the psychoneuroses

which may also have developed in much the same manner. Also we find

cases that have been justifiably considered to be psychoneuroses devel-

oping into psychoses in some inexplicable fashion. From a practical point

of view, cases of this type should be dealt with as combinations of both

psychoses and psychoneuroses. The etiologic factors of a psychoneurotic

type should be adequately treated although in the management of the case

it should be borne in mind that psychotic manifestations may develop.

Special consideration should be paid to the personality disturbances that

develop in the involutional and senile periods. It is highly probable that

we have been too prone to consider them all as depending entirely upon

organic tissue destruction. Actually we find that environmental stress

and strain, previous life experiences, and numerous conditioning factors

are of the utmost importance in the development of a large number of

these conditions.

Constitutional Personality Deviations. A great deal of controversy

has developed in relationship to the differential diagnosis between psycho-

genically produced personality maladjustments and those which depend

upon faulty endowment. We have already referred to this in our dis-

cussion of constitution. Furthermore, the subject is to be dealt with in

other chapters of this book (see Chapter 30 by Preu, Chapter 27 by

Stearns, Chapter 26 by Lowrey, and Chapter 25 by Kanner). At this

point it is sufficient to emphasize that constitutional defects in personality

such as the psychopathies and mental deficiency do not preclude the

28] THE PSYCHONEUROSES 857

further superimposition of psychoneurotic manifestations. This would

mean, of course, that successful treatment of the latter would still leave

the original defect. At the same time it must be stressed that what may

often appear to be an inborn defect (and we would include here inter-

ference with the intellectual functions) may actually depend upon such

mechanisms as social rejection, faulty conditioning, early fixations, frus-

trations, and so on. We often find an improvement in adjustment in

those cases where such causes are found and removed or ameliorated.

Malingering. This term has been used to designate consciously

motivated, deliberate, and sustained simulation of symptoms in order to

secure a desired end. It is unfortunate that in the minds of most people

this has become almost synonymous wtih psychoneurosis. It should be

appreciated that although psychoneuroses, too, are related to some defi-

nite purposes these are neither conscious nor need they be actually

desired by the adult person. As a result, we find that the psychoneurotic

symptom is frequently not related at all to the situation in which the

person finds himself at the time, but is relevant to a much earlier setting.

Similarly, because it depends upon unconscious motivation, the psycho-

neurotic, unlike the malingerer, not only does not object to examination

but actually searches for frequent and thorough investigation of his symp-

toms. Secondly, it should be emphasized that the symptoms described

above are just as characteristic of the psychoneuroses and are as difficult

to simulate as are the symptoms of organic disease. But it must also be

remembered that malingering is not really a normal reaction and may in

itself depend upon a personality organization which could profit from

an analytic revision and readjustment. Finally it must be borne in mind

that some of the cases may be combinations of both and whatever the

attitude of the physician may be to the malingering component he should

regard the psychoneurotic element as an expression of disease and treat

it as such.

Treatment

In any discussion of a medical subject, it is important to include some

statement concerning that phase of it which, to the physician, forms the

goal of his work that is, the treatment. It is obvious, of course, that in

the present discussion we cannot take up the techniques as they are prac-

tically applied, and, for those interested, references will be given in the

bibliography. In addition to this a special chapter on treatment is to be

included in the handbook (see Chapter 34 by Appel). Here we should

like to mention only the general principles of treatment in the psycho-

neuroses, the goals toward which the therapist aims, and some indication

of the methods available. We must emphasize primarily that treatment,

particularly in this field, does not presume to provide substitutes for dis-

turbed functions but is dependent upon the ability to mobilize whatever

assets the patient has and guide him toward a better use of these in

dealing with his particular problem. In order to do this the therapist

858 PERSONALITY AND THE BEHAVIOR DISORDERS [28

must aim first at two primary objectives. These are : (1) a proper evalu-

ation of the personality functions in relation to the given setting, which

will set clearly before us both the problem and the life experiences that

have led up to it ; (2) an understanding of what useful assets the person

possesses and how these can be utilized in the readjustment. An analysis

of the situation when it succeeds in attaining these two objectives forms

the basis of a rational therapy of the psychoneuroses. In addition to this,

however, and in most cases to be considered as auxiliary to it, we have at

our command a series of other therapeutic methods the purpose of which

is to treat symptoms as they arise during the period prior to the success-

ful completion of the rational treatment and other manifestations of poor

health which may be only incidental to the neurosis. This is what we

call symptomatic treatment and it should be understood by both the

therapist and the patient that it is either a temporary stop-gap or ancillary

measure and is not to be taken for the treatment of the disease as such.

Rational Treatment. It is useful to remember in carrying out any

form of rational treatment that we are trying to accomplish the following

things: (1) The grasp of relationships in the given setting. This is the

primary task of the analysis of the person's relationships to his environ-

ment at the time of the development of the problem and a search for

the dynamics in terms of life experiences which have led up to the

establishment of the present difficulty. (2) Emotional participation. The

therapeutic success of such work depends materially upon the degree of

emotional contact that exists between the patient and his physician and

the extent to which the patient is willing to throw himself into the work

emotionally as well as intellectually. Merely attaining a verbal under-

standing of the problem and its dynamics without actually reliving the

affective components of the incidents leading up to the problem is not

likely to benefit the patient any more than if he were to be told of the

occurrences in the life of someone else. (3) The removal of causative

factors. Where a social situation exists which is not compatible with a

proper adjustment of the patient regardless of how well he appreciates

the relationships and feels their importance, it is essential to help the

patient extricate himself from such deleterious circumstances. In addi-

tion, therefore, to the analysis, it is important in a great many cases to

undertake social therapeutic measures in order to remove as far as

possible the factors which contribute toward creating the problem.

(4) Reconstruction and emancipation. It is a well-known fact that in

most cases if the treatment is successful the patient at first develops a

strong emotional attachment to and dependence upon the therapist. His

ability to act independently in the post-treatment period is as vital a

need as is the understanding of the situation and the eradication of the

cause. No treatment, then, should be considered as completed unless this

dependence upon the therapist is dissolved and the patient is rehabili-

tated to the extent where he can act on his own resources. This is espe-

28] THE PSYCHONEUROSES 859

cially important in cases where the patient is being treated in an institu-

tion or, as it may sometimes be necessary, a\\ay from the situation in

which he lived before and to which he has to return.

A number of methods have been developed for the purpose of carry-

ing out rational therapy of this type. Perhaps the most systematically

organized of these is the psychoanalytic method introduced by Freud and

further developed by some of the representatives of that school. More

commonly used and less time-consuming is a method which can be

termed exploratory and which, although utilizing to a large extent con-

tributions of psychoanalysis, is nevertheless more direct and technically

less complicated. It consists essentially in a thorough face-to-face analysis

of the history of the person with particular reference to those incidents

that appear to be logically related to the origin of the problem. A great

deal of importance is to be placed upon the proper guidance and re-

education of the patient wherever the facts brought up by analysis indi-

cate the existence of faulty judgment, immature attitudes, lack of insight,

and so on. Numerous other methods have been described both before

and after the introduction of the psychoanalytic method. It must be

appreciated that none of the methods should be established as necessarily

the only one which must always be used. Perhaps the most successful

procedure is to be guided by the developments as one works with the

patient, and it may be useful to shift from one method to another.

Symptomatic Treatment. The psychoneurotic symptoms are quite

frequently sources of discomfort or pain both to the patient and to the

therapist. Persistent vomiting or headaches, convulsions, or insomnia in

addition to the suffering they cause may also interfere with the proper

administration of treatment. Under such conditions it becomes impera-

tive to utilize methods of treatment which deal directly with the symptoms

even though they do not strike at their roots and therefore are not likely

to produce lasting results. Sedatives, anodynes, suggestion, and hypnosis

are all useful aids, provided, as we said before, the physician and the

patient both realize their value as temporary measures only. Finally, we

must remember that psychoneurotic patients are just as likely to suffer

from incidental somatic diseases as any other person. A good therapist

will see the wisdom of dealing with such problems as they arise. This

serves two purposes. Inasmuch as the old dictum of "sound mind in a

sound body" contains a great deal of truth, the correction of physical

ailments is of great help in increasing the capacities of the patient to

deal properly with his personality problem. In addition to that, con-

fidence of the patient in the good judgment and healing abilities of the

physician goes a long way in securing the success of treatment, regard-

less of what kind it is. The interest that the physician shows in the

patient as a whole person and the fact that he pays attention even to

minor physical disturbances will enhance this confidence and render the

patient more receptive to the advice and guidance of the therapist.

86o PERSONALITY AND THE BEHAVIOR DISORDERS [28

BIBLIOGRAPHY

ADLER, A. 1917. The neurotic constitution. New York: Moffat-Yard.

ANDERSON, O. D., & PARMENTER, R. 1941. A long-term study of the experimental

neurosis. Psychosom. Med. Monogr., 2, Nos. 3, 4.

BROWN, J. F. 1940. The psychodynamics of abnormal behavior. (With the col-

laboration of K. A. Menninger.) New York: McGraw-Hill.

DUNBAR, H. F. 1938. Emotions and bodily changes. New York : Columbia Uni-

versity Press.

EBAUGH, F. G. 1940. The care of the psychiatric patient in general hospitals.

Chicago: American Hospital Assn.

FENICHEL, O. 1934. Outline of clinical psychoanalysis. New York : Norton.

FREUD, S. 1895. The justification for detaching from neurasthenia a particular

syndrome: the anxiety neurosis. In Collected papers, Vol. 1. London: Inter-

national Psychoanalytical Press, 1924.

1909. Selected papers on hysteria and other psychoneuroses. (Trans, by

A. A. Brill.) Nerv. went. Dis. Monogr., 1920, No. 4.

1920. Introductory lectures on psychoanalysis. New York: Liveright.

1924. Neurosis and psychosis. In Collected papers, Vol. 2. London: Ho-

garth, 1924.

GLOVER, E. 1941. Psychological effects of war conditions. Int. J. Psycho-Anal.,.

23, 132.

HENDRICK, I. 1934. Facts and theories of psychoanalysis. New York: Knopf.

JONES, E. 1920. The treatment of the neuroses. London: Bailliere.

KARDINER, A. 1941. The traumatic neuroses of war. Psychosom. Med. Monogr.,

1, Nos. 2 & 3.

KRETSCHMER, E. 1923. Hysteria. (Trans. by,O. H. Boltz.) Nerv. ment. Dis.

Monogr., 1926, No. 44.

1925. Physique and character. New York: Harcourt, Brace.

MALAMUD, W. 1931. The psychotherapy of neurasthenia. /. la St. med. Soc.,

21, 489.

1936. Modern trends in psychoneurotic reaction types. /. la St. med. Soc.,

26, 625.

1938. The psychoneuroses. In Tice Practice of medicine, Vol. 10. Hagers-

town: Prior. Ch. 18.

MASSERMAN, J. H. 1943. Behavior and neurosis : An experimental psychoanalytic

approach to psychobiologic principles. Chicago : University of Chicago Press.

MILLER, E. (Ed.) 1940. The neuroses in war. New York: Macmillan.

NUNBERG, H. 1932. Allgemeine Neurosenlehre. Bern: Huber.

RADO, S. 1939. Development in the psychoanalytic conception and treatment of

the neuroses. Psychoanal. Quart., 8, 427.

Ross, T. A. 1937. The common neuroses. Baltimore : William Wood.

SHELDON, W. H. 1940. The varieties of human physique. New York: Harper.

STRECKER, E. A. 1930. Psychiatric education. Ment. Hyg., N. Y., 14, 797.

WECHSLER, I. 1929. The neuroses, Philadelphia: Saunders.

WHITE, B. V., COBB, S., & JONES, C. M. Mucous colitis. Psychosom. Med.

Monogr., 1, No. 1.

Chapter 29

THE FUNCTIONAL PSYCHOSES

By NORMAN CAMERON, Ph.D., M.D.

UNDER THE FUNCTIONAL PSYCHOSES it is customary to group those

sweeping disorders for which no organic lesions and no toxins have con-

sistently been demonstrated, namely, schizophrenia, paranoia, mania, and

most severe depressions. This use is a common one in medicine where,

for example, functional heart disorders are recognized as a clinical group

for which neither drugs, toxins, nor lesions are responsible. Three inter-

pretations are current with respect to the functional psychoses : ( 1 ) thai

their determining factor lies in a hidden lesion, somewhere in the brain

or other organ, that has not as yet been discovered, or in predetermined

hereditary defect comparable with the situation in Huntington's chorea,

or that some unknown toxins, infections, or general metabolic disorders

are directly responsible ; (2) that organic activity or change when present

is quite incidental, the real disturbance being located in a semi-inde-

pendent psyche with its own needs and other-worldly attitudes; and (3)

that the influences of environmental, social, and personal organizations

are fundamental, the fact of biological activity in every form of human

behavior being always taken into consideration and accepted as suf-

ficiently demonstrated. The first may be termed the structural view, the

second is the psychic approach, and to the third may be applied the term

bisocial.

It makes a great deal of difference both in practice and in research as

to which view the worker embraces. (1) The structuralist, who repre-

sents the traditional medical attitude, will direct his efforts toward the

organism as a structural, physiological, and biochemical unit, leaving the

environmental, social, and personal aspects to the psychologist, the soci-

ologist, and the theologian, as if it were their special concern. His con-

tributions throw light upon the inner workings of the system of organs

which go to make up the human machine. (2) The advocate of a separate

psyche with its own phenomenal world is the direct intellectual de-

scendant of rationalistic philosophy. For him there are also two worlds

of reality, but he believes that the efficient causes of human action are to

be found in a special psychic realm. His contributions focus upon the

861

862 PERSONALITY AND THE BEHAVIOR DISORDERS [29

desires, thoughts, and dreams as parts of that psychic realm, and tend

to reinterpret organic, social, and environmental reality in its terms, or

else to relegate it to the history takers. (3) The remaining attitude

differs chiefly in rejecting the dualism of both the other two, and in

adopting the simple pragmatic stand that the world we move about in is

not only the real world but the only world, and that desiring, thinking,

dreaming, and doing all belong in it. For them the psyche is a myth.

The contributions of these pragmatists in the study of personality and

behavior disorders emphasize man as a person operating in an environ-

mental field, whose difficulties may arise from several sources visceral,

environmental, personal, or interpersonal. The distinct opposition of the

pragmatic and the psychic views has been recently set forth by N. Cam-

eron (1942a, 1943d).

The practical difference that general orientations make becomes very

evident in the different ways of handling the functionally disordered.

Strong faith in the role of heredity and constitutional type leads to mere

diagnostic sorting and sterilizing ; belief in toxins, infections, lesions, and

metabolic disturbances as the basic disorder leads to medicinal and

surgical measures or else to a fatalistic custodial attitude ; conviction as

to the primary efficacy of a separate psyche encourages introspective

techniques and mentalistic interpretations ; while belief in an everyday

world of reality with everything in it leads to a naturalistic orientation

which compels the devotion of adequate attention to all human function-

ing, irrespective of traditional and academic divisions.

The Major Problems

Etiology. There is no topic around which greater controversy cen-

ters than that of the origins and the exact character of the functional psy-

choses. Each hypothesis has its protagonists, its evidence, and its prac-

tical results, as set forth for instance in the symposium on the material

of human nature and conduct in which the approaches of the psychologist,

the psychoanalyst, the biochemist, the psychopathologist and the psycho-

biologist are outlined (Meyer, 1935). To each set of postulates we owe

the opening up of some special field of investigation in which the work-

ers have looked for solutions to the questions which their particular

approach raises.

HEREDITY. The role of inheritance is by no means settled. Apart

from the inevitable statistical problems involved, the most trying task is

that of determining how dependable the information is regarding ascend-

ants and collaterals of the patient. Even in a stable population there is

so much concealment from generation to generation, because of the

disgrace implied by such familial taints as "insanity," that the most

reliable informant may unknowingly omit important data. In the other

direction, past generations made little distinction between psychosis,

oligophrenia, epilepsy, cerebral accidents, and antisocial behavior. What

they did pass on to their descendants consisted largely of inexpert inter-

29 ] THE FUNCTIONAL PSYCHOSES 863

pretations which the descendants then give to the investigator as facts.

Finally there is little uniformity within the profession as to diagnostic

criteria, so that one cannot even be sure in making studies from case

records that the same term is used similarly by different workers (Noyes,

1939).

It seems to be generally accepted that the functional psychoses appear

significantly more often in certain family trees than in the general popu-

lation (N. Lewis, 1923; Myerson, 1925; Landis and Page, 1938; Kail-

man, 1938). Statistical analyses based upon records of the New York

State psychiatric hospitals, whose standards are relatively uniform

(Cheney, 1934), have been made by Pollock, Malzberg, and Fuller

(1939). According to these authors, functional psychoses appear sig-

nificantly in excess of the complete expectation, provided a correction be

made for the anticipation of further cases among the relatively young.

Whether the psychotic attack shall be predominantly affective in char-

acter, or belong more to the disorganized psychoses, seems to them to be

related more to the family history than to the precipitating situation;

for there is a signficantly greater incidence of either one or the other in

certain family groups, when corrections have been made for anticipation

because of the youth of siblings of patients at the time of study. In their

statistics, the particular conditions at the time of onset under which

affective psychoses appear seem not to differ essentially from those under

which schizophrenic and paranoic disorders arise. Presumably the per-

sonality organization of the individual at the time is of great importance

in determining the general character of the disturbance ; and this organ-

ization they ascribe chiefly to family inheritance. What evidence there

is indicates that the single-factor hypothesis is incapable of accounting

for inheritance in the functional psychoses (Malzberg, 1940).

PHYSICAL CONSTITUTION. Attempts to tie up bodily types with the

psychoses have a long history ; the writings of the ancients and the medi-

evals are peppered with them ; current popular beliefs in the relationship

are strong. In modern times the psychiatrist Kretschmer (1925) has

done most to awaken serious study of this problem. What might have

been a valuable lead, however, has suffered at his hands from inaccurate

method and unprecise formulation, and from the difficulty in getting

agreement as to diagnosis in a sizable proportion of cases (Wertheimer

and Hesketh, 1926; Raphael, et at., 1928). Gibbs has made studies of sex

development in schizophrenics (1923, 1924). Critical analyses have been

presented by Burchard (1936) and Farber (1938), while Cabot (1938)

has indicated the indirect social effects of physical characteristics upon

the person having them. A new and more detailed study, conceived

along Kretschmerian lines, has recently been carried out by Sheldon,

et al. (1940, 1942, see also Chapter 17).

CENTRAL NERVOUS SYSTEM. Organized attempts to establish definite

brain pathology that can be definitely and dependably correlated with the

functional psychoses have been carried out for many decades. Among

864 PERSONALITY AND THE BEHAVIOR DISORDERS [29

the more influential workers in relatively recent times should be men-

tioned Southard (1910, 1914), Mott (1920a), Nissl and Alzheimer

(1921), Josephy (1923), and Buscaino (1924). General reviews with

bibliographies may be found in Stransky (1911), Lange (1928), Spiel-

meyer (1930), Steiner (1932), and N. Lewis (1936). A critical analysis

of technique and criteria for adequate examination of autopsy material

comes from the hand of Dunlap (1923, 1928) who found that, when

adequate criteria were followed, it was impossible to single out the brains

of schizophrenics from among a group of nonschizophrenic ones. Elvidge

and Reed (1938) have attempted to diagnose schizophrenic brain changes

during life by means of biopsy material removed through trephined open-

ings. Stein and Ziegler (1939), stimulated by physiological studies of

thalamic function in relation to emotion, have subjected the thalami of

schizophrenic and of manic-depressive patients to a biometric analysis,

but without conclusive results.

In critically reviewing the evidence for and against specific structural

pathology for schizophrenia, Conn (1934) considers the quest to have

been progressively unproductive, while Skalweit (1938) remains con-

fident, in spite of the failures and mutual contradictions among struc-

turalists, that an anatomical basis will finally be demonstrated. There

always remain those who like Jung (1908) believe in the presence of

toxic or intermediate metabolic substances in excess, the effects of which

appear clinically as schizophrenic or affective disturbances but which may

not leave pathology to be found at autopsy. This would be a strong fort

into which to retire were there no convincing evidence of psychogenic

factors in the predisposition to or precipitation of these illnesses. In

addition the recent work that has been done upon the problem of de-

terioration, particularly the studies of Kendig and Richmond (1940),

seems to make the position of those who have insisted upon the preva-

lence of organic defect, at least in schizophrenia, almost if not quite

untenable.

PSYCHOSURGERY (LoBOTOMY, LEUCOTOMY). In spite of our rather

meager information concerning the neurophysiological correlates of abnor-

mal behavior, brain surgery is being carried out quite widely in the treat-

ment of functional disorders. Moniz (1937) developed a technique

variously referred to as psychosurgery, lobotomy and leucotomy. This

operation originally involved the production by a blunt loop dissection

in the prefrontal subcortex of necrotic tissue "cores" ; access to the brain

was achieved through bilateral burr holes. Watts and Freeman (1938)

have radically altered the procedure by inserting a blunt instrument hori-

zontally through burr holes in the coronal suture 6 cm. above the zygo-

matic process on each side. After certain preliminaries, a periosteal

elevator is passed into the brain to a depth of 5 cm., swung in an arc

downward and upward as far as the bony opening permits and then

withdrawn ; the incision is then irrigated and the galea and scalp inci-

sions sutured closed.

29 ] THE FUNCTIONAL PSYCHOSES 865

The goal of this operation is the severance of connection between

thalamus and prefrontal cortex, although more destruction than this may

occur. Freeman has summed up the rationale for this therapy as follows :

"We believe that the frontal lobe is concerned with the picture that we

have of ourselves, both as a unit of society and a collection of organs.

The thalamic connection mediates the affect attached to that ego-image.

When the image of the ego gets too painful for the individual so that

a psychosis develops, and the egocentricity gets so marked that the

patient thinks that people . . . are interfering with his adaptation to

life, then some whittling down of this ego-ideal, let us say, some bleaching

of the affect attached to the ego, renders the individual again capable of

taking interest in outside things" (1942). From their results Freeman

and Watts conclude that the central or Rolandic fissure divides the cere-

bral cortex into two portions of essentially different function, so that,

"Just as the post-Rolandic cortex is concerned with the past, the pre-

Rolandic cortex is concerned with the future. Aside from certain small

areas . . . the frontal cortex is, according to our hypothesis, concerned

with the projection of the whole individual into the future" (1942, pp.

302-303). Clinical descriptions of the after-effects of psychosurgery

appear in the papers of Watts and Freeman (1938), Lyerly (1941), and

Strecker, Palmer, and Grant (1942). The last-named consider this to

be a mutilating operation and would restrict it to chronic psychotic cases

with whom other methods have already proved fruitless. Bailey (1942),

however, interprets the objections of psychiatrists to such radical treat-

ment as "indignation resting on the subconscious conviction that the

removal of the brain robs a man of his 'soul'."

A recovery strikingly similar to some described for psychosurgery

from severe depression has been reported (Lebensohn, 1941) in which

a self-inflicted bullet wound involving both prefrontals left the patient

without the depression and with the emotional flattening, euphoria, face-

tiousness and lack of foresight reported for lobotomized patients. The

remarkable summary of methods, results and theory in this field by Free-

man and Watts (1942) should be consulted.

FOCAL INFECTIONS. Surgery was at one time extensively employed

in attempts to eradicate focal infections which were believed to be the

determining cause of functional psychoses. Hunter, in the early days of

bacteriology (1900), connected chronic sepsis with neurasthenia, de-

pressions and severe "nervous breakdowns." Cotton (1921) summar-

ized the spectacular therapeutic results he had obtained through dental

extractions, and by drainage or surgical removal of viscera, including

colonic resection; and he urged (1933) the subordination of everything

else to a surgical attack upon the functional psychoses, mental deficiency,

and delinquency. Hunter (1927a, 1927b) and Moynihan (1927) pre-

sented further data, the former proclaiming the discovery of the role of

focal infections to be "a new era" in psychiatry and even suggesting that

many functional psychoses be renamed septic psychoses. These interpre-

866 PERSONALITY AND THE BEHAVIOR DISORDERS [29

tations were promptly challenged by Henderson (1927) and Menzies

(1927) and later by the work of Beck, Ogden, and Whelen (193Sa,

193Sb), since when evidence has been collected on both sides (Kopeloff,

1941). Interest in this new era has waned considerably during the past

decade and others have taken its place; but one still finds psychotic

patients whose first treatment has been wholesale extractions or surgical

subtractions.

ENDOCRINES. Investigations of the endocrine system have likewise

given inconclusive results. Kraepelin (1909-1913) taught that dementia

praecox (schizophrenia) is due fundamentally to a metabolic disorder

resulting in some form of autointoxication. Mott (1920a, 1920b, 1922a),

on the basis of autopsy material, reported consistent pathological changes

for schizophrenics in gonads, adrenals, and pituitary, together with de-

generative cell processes especially in those of the cerebral cortex and

the basal ganglia. These degenerations he attributed to inherited vital

deficiency in the fertilized ovum. N. Lewis (1923) found in similar

patients characteristic degenerative changes in testes, adrenals, and thy-

roid, although not in the pituitary. Morse (1923) has seriously chal-

lenged such claims on the basis of further pathological studies, calling

attention to the many technical sources of error in determining norms for

endocrine tissue, and to the marked effects of malnutrition and of fatal

disease upon endocrine structure, which the other workers had appar-

ently not considered. Lewin (1927) found no evidence in his material

for "anatomico-psychiatric correlation" and characterized the hypotheses

advanced by others on the basis of comparable material as untenable,

particularly with reference to dementia praecox.

Bamford (1929) contended that in acute dementia praecox there were

demonstrable infantilism of the cardiovascular system, a macrocephalic

brain, and fibrosis of the endocrine glands. N. Lewis (1931) presented

autopsy reports on eight cases of affective disorder which in his opinion

indicated excessive compensatory reactions in both circulatory and endo-

crine structures; but his cases were aged 45, 51, 60, 62, 65, 76, and 85

years respectively and only one, who suicided, was free of complicating

systemic factors preceding death. Hutton and Steinberg (1936) reported

pituitary dysfunction in functional psychoses, and Clegg (1937) claimed

gonadal deficiency in schizophrenia and pituitary deficiency in the affec-

tive group. Carmichael (1938), however, has called attention to the lack

of crucial evidence for or against close relationship between endocrines

and mental disorders. The endocrinologist Hoskins (1941) characterizes

the relationship between the endocrines and personality as indeterminate

in broad outline and in detail definitely confused. He doubts that any

relationship between endocrines and behavior disorders has been demon-

strated and considers this an important but almost unexplored area.

BIOCHEMISTRY AND PHYSIOLOGY. The case for and against the

hypothesis that consistent biochemical changes are the fundamental facts

in the pathology of the functional psychoses has been critically reviewed

29] THE FUNCTIONAL PSYCHOSES 867

by Malamud and Miller (1931) and by McFarland and Goldstein (1938,

1939). The dependable and consistent results they were able to sort out

were very meager and even those were difficult to interpret. Physio-

logical studies in relation to the functional disorders in general have been

reviewed by Jasper (1937), Shock (1939), Knott (1941), D. Cameron

(1941), Jasper (1941), Liddell (1941), and N. Cameron and Harlow

(1943), and with special relation to manic and depressive disturbances

by N. Cameron (1942b). Shipley and Kant (1940) have reviewed

physiological and psychological aspects of chemical shock therapy. Re-

search upon the physiology and biochemistry of the functional psychoses

is being vigorously prosecuted at the present time. It cannot fail ulti-

mately to prove enlightening in some direction; but whether or not it

will produce the final and complete answer, as many hope and expect, is

another matter. Final and complete solutions of the functional disorders

seem less likely than they did 50 years ago when tendencies to study the

individual as an isolated organism were less challenged than they are

today.

PSYCHOGENESIS. There are three main groups of persons who give

first place to a psychogenic etiology for the functional psychoses,

(a) One follows the older academic psychologists in looking upon the

mind or psyche as something separate from the body or soma, the psyche

somehow exerting an effective influence upon the soma and the soma

upon the psyche, both through mediation of the central nervous system.

This group of workers usually ascribes the greater reality to the soma,

regarding the psyche as intangible, often as unpredictable, but at the

same time as potentially a powerful influence. This is essentially the

position of the psychosomatic school ; the weak link in their causal chain

is always the question of just how psyche and soma interact, a question

which has never received a scientifically acceptable answer.

(b) The second group includes those whose theories of the uncon-

scious crystallized in the rationalistic atmosphere of the late nineteenth

and early twentieth centuries (Zilboorg and Henry, 1941), mainly

through Freud's work. The many varieties within this group agree in

ascribing the greatest effectiveness and reality to unconscious components

of the psyche which to them are more primary and causal than either

conscious psychic processes or somatic conditions. They, also, have been

unable to solve the riddle of the mind-body or psychosomatic dualism

which they have inherited along with their general philosophical position ;

but there is currently a concerted effort being made in this direction, in

which both groups are participating (Dunbar, 1938). A minority of psy-

choanalysts is inclined to regard the functional psychoses as primarily

organic diseases (e.g., Schilder, 1938, 1942).

(c) A newer interpretation of psychogenesis is unique in rejecting

the traditional separation into a world of psychic and a world of physical

reality. It lies farthest from theories of mental causation and closest to

pragmatism and instrumentalism (Cameron, 1942c, 1943d). The term

868 PERSONALITY AND THE BEHAVIOR DISORDERS [29

"psychogenesis," although a misnomer, is retained for the same reason

that modern psychiatry retains "hysteria," i.e., it has become too thor-

oughly incorporated into the literature to be dropped. Instead of search-

ing for first causes, however, this approach attempts to determine the

conditions under which functional disorders arise and progress or dis-

appear, be these predominantly in fantasy, conflict, disappointment, mal-

adaptation, or in physiopathology, in trauma in the interrelationships

with other persons, or in social, economic and other environmental cir-

cumstances. Such so-called "mental processes" as desire and fantasy, for

example, are included as complex forms of organismic behavior, which

involve biological activity in the same sense that signalling or talking to

oneself or to another person does. Defective development of role-taking

skills in the individual, as an important predisposing factor in functional

disorders, has recently been introduced (Cameron, 1938a, 1943a, 1943b).

For this view the functional psychoses are major disorders in which the

direct effects of structural, physiological, and biochemical pathology are

minimal or absent, while personal and social factors are maximal.

Adolf Meyer, although at the time brain pathologist at Worcester

State Hospital, was among the first to present functional psychoses as

reactions of the total personality in terms of social environment and per-

sonal organization (1906). He indicated the development of dementia

praecox from normal reactions, as habit deteriorations, without falling

back upon either pseudoneurology or psychosomatic dualism. According

to him, the slightness of histological evidence "suggests a mere bank-

ruptcy under anomalous or even ordinary demands with insufficient funds

of adjustment" to meet them (1906, 1910a, 1910b). He worked out a

conception of paranoia that did justice both to the unusual personality

organization of the patient and to the forms of maladjustment in paranoiacs

(1903, 1908, 1913). In 1896, Freud reported a case of "chronic para-

noia" which he interpreted as a defense against childhood sex memories

and homosexual fantasies; and in 1911 he came out with an analysis of

the published autobiography of a paranoid schizophrenic patient of Flech-

sig's, in which Freud set forth his oft-quoted paradoxical denials and

reversals of homosexual wishes (Knight, 1940).

Stransky (1903) postulated a schism between emotion and intellect,

or thymopsyche and noopsyche, as the fundamental process underlying

the deterioration in dementia praecox. This formed a basis not only for

Bleuler's theory, but also for the rationale behind lobotomy, or "psycho-

surgery," which tries deliberately to produce apathy by a cerebral insult

designed to separate thinking from emotion (Freeman and Watts, 1942).

Bleuler (1906) and Jung (1908, 1939) described emotional interference

and distortion in relation to paranoic and to disorganized thinking re-

spectively. Gross (1906) gave reasons for considering the illness a dis-

integration rather than dementia and urged adoption of Wernicke's term

Dementia sejunctiva; while Zweig (1908), reporting a case with an

onset after the age of 30 years, called attention to the inappropriateness

of the term praecox and suggested as a substitute Dementia dissecans*

29] THE FUNCTIONAL PSYCHOSES 869

Bleuler (1911) wrote an extensive monograph on dementia praecox to

which he gave the name of schizophrenia, which is the most acceptable

term today. Although Bleuler also considered dissociation to be funda-

mental in schizophrenia, he was never able to free himself from the his-

tological theories of Alzheimer, Nissl, and Josephy, who maintained that

cortical degeneration and glial proliferation were the essential parts of

the disease picture (Bleuler, 1930a, 1930b). Accounts of the evolution

of modern etiological theories of schizophrenia have been given by Meyer

(1928b), Gruhle (1932c), Conn (1933), and Wittman (1937) ; of para-

noia by Meyer (1913) and Kehrer (1928) ; and of the effective group

by Stransky (1911), Lange (1928), Jelliffe (1931), and A. Lewis

(1934a). The psychoanalytic theories have been traced by Rickman

(1927) and Fenichel (1934).

The conviction is becoming widespread among psychiatrists, psychol-

ogists, and sociologists that the same kind of personal, social, and en-

vironmental factors are operative in preparing the ground for and in

precipitating the functional psychoses as in the case of the neuroses. The

intimate interrelationship between neuroses and functional psychoses has

been brought out by Freud (1896), Meyer (1906), Dooley (1931),

Myerson (1936, 1938), Miller (1940), and Caldwell (1941). There is

nothing to be gained by listing the factors that have been implicated

in the precipitation of functional psychoses ; obviously almost any incident

toward which an individual may have become sensitized can tip the

balance. Sullivan (1925, 1927a), Harrowes (1931a), Bonner (1931),

Brew (1933), and Fox (1942) discuss psychogenic etiological factors

in the affective psychoses ; Hutchings, Cheney, and Wright (1928), Witt-

man (1937), and Terry and Rennie (1938), in the schizophrenias.

Duration and Prognosis. The duration of the functional psychoses

is highly variable. Obviously many of the factors involved in precipi-

tating the illness may operate in perpetuating it. Personality organiza-

tions that are too rigidly organized (Muncie, 1931) or too loosely

(Diethelm, 1933) are apt to recover slowly or not at all. Rennie (1942)

finds recovery in affective disorders correlated with an "outgoing per-

sonality." In general, a large proportion of paranoic and schizophrenic

patients run a long course, and recover only partially or not at all.

Involutional melancholias, because of aversion and anxiety characteristics

as well as relatively advanced age, show a great tendency to become

chronic, as do also a few manias. Uncomplicated depressive, manic,

and some schizophrenic attacks, in persons with reasonably good per-

sonality assets, have a fairly good outlook provided treatment is begun

early. What therapeutic method is employed makes far less difference

than how early and how selected the cases are (Stalker, 1939; Notkin,

etal, 1939, 1940).

Great confusion has resulted in attempts to compare (a) chemically

treated patients with (b) those treated by planned psychiatric methods

and with (c) those left to themselves in a protected environment, be-

870 PERSONALITY AND THE BEHAVIOR DISORDERS [29

cause there has been a striking failure to state in the reports just how

the patients were selected for specific therapy. This error, plus the

suggestibility of the patients, the physicians, and the authors, have led

to the same misleading claims in relation to endocrine therapy, to the

elimination of "autointoxication" and focal infections, to psychosurgery

and in relation to some of the more recent shock therapy (Henderson

and Gillespie, 1940, Ch. 9). It is well known that reports of 90% to

95% complete cures have more than once been made in the literature,

and by honest and responsible practitioners of the past, for forms of

treatment that today are no longer considered worth talking about

(Deutsch, 1937; Cheney and Drewry, 1938; Diethelm, 1939). Even

the medical historian may lose his perspective. Garrison in 1924 indi-

cated that the Abclerhalden ferment reaction had discredited Meyer's view

of schizophrenia as a functional rather than a gonadal disorder (pp. 700-

701) ; but within a decade the Abderhalden technique had proved to be

mere self-deception.

Prognostic studies in relation to a wide variety of factors have been

reported, for the affective group, by Strecker, et al. (1931), A. Lewis

(1936), Anderson (1936), Hunt (1938), and Rennie (1942) ; for the

schizophrenias, by Sullivan (1924, 1928), Harrowes (1931b), Strecker

(1931), N. Lewis and Blanchard (1931), Terry and Rennie (1938),

Malamud and Render (1939), Stalker (1939), Henderson and Gillespie

(1940), and Gottlieb (1940); and for the clinical mixtures of these,

sometimes called schizaffective psychoses, by N. Lewis and Hubbard

(1931) and Hunt and Appel (1936).

Classification. All current attempts at classifications of functional

personality disorders are unsatisfactory ; this is true for the neuroses as

well as for the psychoses. No causal organisms have been implicated,

hence we cannot fall back upon them as we can in the specific infectious

diseases. There are no characteristic organic lesions as there are in the

systemic diseases ; and the central nervous system exhibits no consistent

changes that can be correlated with the syndromes as in neurological

disorders. Physiological and biochemical studies do not support the

older assumptions that fundamentally different metabolic processes under-

lie different forms of personality disorder (McFarland and Goldstein,

1938, 1939; Cameron, 1942b).

To date the least unsatisfactory classifications are those based upon

clinical and behavioral differences. These suffer in a pronounced form,

however, from the same limitations as those found in other clinical classi-

fications ; for one seldom encounters a pure clinical case of anything out-

side a textbook (Cameron and Cameron, 1938). It is unusual to find

a depression without a little disorganization, or schizophrenia without

some evidence of elation, sadness or hopelessness (Bonner and Kent,

1936). Even the manic patient is apt to have brief episodes of real sad-

ness, or paranoid delusions and perhaps some incidental disorganization.

Paranoics often show euphoria and elation, or show depression even to

29] THE FUNCTIONAL PSYCHOSES 871

the point of suicide. In any discussion of clinical groupings, however,

these admixtures, shadings, and contradictions have to be largely ignored

in the interest of clarity ; but it is important that they be not completely

forgotten afterwards. Most of the confusion and the contradictions in the

literature on functional psychoses can be traced to the wholly unjustifiable

practice of treating the heterogeneous mass of major depressive and

manic disturbances as if they really constituted a single illness,

Kraepelin's "manic-depressive insanity/* and of lumping together the

schizophrenic disorders likewise as a homogeneous disease entity as

though it were as uniform as chicken-pox.

It is important for persons working in the abnormal field to realize

that the current official psychiatric classifications are not based upon

final and convincing scientific evidence. They are children of practical

necessities. Decisions as to the group in which a given behavior disorder

shall fall depend upon schemata that actually were adopted, both in this

country (Cheney, 1934) and in Great Britain (Fleming, 1933), by a

majority vote of the practicing members of large associations. In some

very fundamental respects these systems of classification represent frank

compromises between dissident factions, as one can readily observe by

reading the successive committee reports (Fleming, 1932, 1933, 1934).

One should therefore avoid an attitude of finality toward the interrela-

tionship among the behavior disorders that our official classifications,

if taken too literally, seem to imply. It is obvious to any reasearch

worker that questions of etiology, of clinical and physiological char-

acteristics, and of the course, the therapy and the prognosis, cannot be

decided for good purely on the basis of a majority vote. The most this

can express is the majority opinion as to a useful expedient in admin-

istrative decisions. It does not necessarily represent even the most

advanced opinion in scientific matters, particularly when the science is

young and the evidence is very conflicting.

Diagnosis. For simplicity's sake this account will follow the classi-

cal division of the functional psychoses into (a) affective disorders,

including mania and depressions, (b) schizophrenic disorganizations,

and (c) paranoic and paranoid psychoses. This follows in general the

Kraepelinian schema adopted in a modified form by the American

Psychiatric Association (Cheney, 1934). In the great majority of func-

tional depressions, hopelessness and either sadness or an overwhelming

anxiety dominate the picture ; in manic excitements optimism with great

joy or self-assertion usually prevail. In both of these latter groups there

is relatively little disorganization of thought, speech and action. The

experienced normal person is therefore more easily able to keep in satis-

factory rapport with these patients than with schizophrenics. The manic

patient is, of course, quite easy to differentiate from the depressed, since

the prevailing emotional disturbance appears to be in an opposite direc-

tion.

The schizophrenic patient can readily be distinguished from mania

872 PERSONALITY AND THE BEHAVIOR DISORDERS [29

and depression if, as is often the case, he shows definite disorganization ;

otherwise the distinction may be arrived at only after prolonged study

of the case. There is still considerable need for better techniques in

uncovering slight or early thought disorganization even though much

research in the past decade or two has been devoted to this problem.

The schizophrenic may be excited or slowed up but, unlike typical

affective patients, his rapport with the experienced normal person is apt

to be definitely poorer and less stable. He usually undergoes a certain

degree of social disarticulation and in severe cases he may become almost

completely shut off from the participative behavior of others (Cameron,

1938b, 1943b). Marked oddities of thought, speech, and action often

develop which may grow into extraordinary permanent mannerisms.

Finally, paranoia deserves separate discussion because of its potential

psychological importance. In the paranoic we are dealing with delusional

systems, often well and convincingly organized, which more or less

dominate the individual's living but do not necessarily lead to note-

worthy disorganization. Outside of the delusional system itself the

person may seem fairly clear and reasonable.

Incidence. Closely tied up with the problems of classification are

those of incidence. Some variation will be found in reports as to the

incidence of the functional psychoses because of existing differences in

classificatory criteria. According to Dayton (1940) there were 12,820

first admissions diagnosed dementia praecox in Massachusetts mental

hospitals between 1917 and 1933, constituting 19.46% of total first

admissions, of whom 6,253 were males and 6,567 females. During the

same period there were 6,368 first admissions of manic-depressives, or

9.66%, of whom 2,552 were males and 3,816 females; there were 1,433

first admissions diagnosed involutional psychosis, or 2.17%, of whom

460 were males and 973 females; and there were 1,340 first admissions

of paranoics, or 2.03%, of whom 484 were males and 856 females. The

highest incidence of dementia praecox was found in males below and in

females above 30 years of age ; while in manic-depressives the highest

incidence for males was above 50 and for females between 30 and 49

years. Paranoia and the involutional psychoses had their range of high-

est incidence between 50 and 79 in both sexes.

Malzberg (1940) bases his figures on first admissions to all mental

hospitals in New York State during the fiscal years 1929-1931. During

this period there were 7,539 diagnosed dementia praecox, constituting

26.3% of total first admissions, of whom 4,163 were males and 3,376

females. There were 3,846 manic-depressive first admissions, or 13.4%,

of whom 1,530 were males and 2,316 females ; 810 diagnosed involutional

melancholia, or 2.8%, of whom 274 were males and 536 females ; and

287 paranoia and paranoic conditions, or 1.0%, of whom 131 were males

and 156 females. Average ages of first admissions diagnosed as dementia

praecox are given as, for males, 31.8 .01 (S.D. in years = 10.5 it .1)

and for females, 36.5 db .01 (S.D. = 11.6 =t .1) ; manic-depressives.

29] THE FUNCTIONAL PSYCHOSES 873

for males, 38.3 , 2 (S.D. = 13.7 .1) and for females, 36.2 =fc .2

(S.D. 12.4 .1); involutional melancholia, for males, 54.9 .3

(S.D. 6.9 .2) and for females, 52.1 .2 (S.D. = 7.0 .1) ;

and paranoia or paranoic conditions, for males 50.1 .7 (S.D. = 11.8

.5) and for females, 50.5 .6 (S.D. = 11.8 db .4). Malzberg also

presents analyses on the basis of environment, marital status, nativity

and parentage, race, order of birth, economic factors, and literacy

(1940).

In interpreting such data as these it must not be forgotten that hos-

pital statistics cannot be applied directly to general population studies.

They represent minimal figures since only those persons whose illness is

fairly marked or whose home facilities are inadequate are usually sent

to these hospitals. The approximately 500,000 patients in mental hos-

pitals could undoubtedly be matched by an equal number who have never

been in one. Paskind has attacked this problem, so far as the affective

group is concerned, in a series of studies (1930a, b, c) reporting data

on over 600 patients seen in private practice and not hospitalized. His

patients turned out to be older on the average than in hospital statistics,

the males slightly outnumbered the females, and the average duration

of the attacks was much shorter than that given in hospital reports.

Major Affective Disorders

Under the major affective or mood disorders are usually grouped the

elated excitements, the retarded depressions, and the anxious and agi-

tated depressions. It is not customary to include here depressive and

elated reactions occurring in the setting of organic brain disease or of

systemic intoxications. In some quarters the depressions of middle

life, especially those occurring in women at about the period of the

menopause, are given separate treatment as "involutional melancholia" ;

in others they are simply included among the other depressions, or else

placed with disorders of metabolism and endocrine function. Minor and

incidental depressions clearly developing out of specific situations are

conventionally grouped with the neuroses. This convention had its

origin in the older theories that distinguished between the profound

depressions as endogenic, i.e., of structural or metabolic origin, and the

milder ones as psychogenic, i.e., psychologically or situationally deter-

mined.

Early History. Recognition of some fundamental relationship be-

tween excitements and depressions goes back into antiquity. Hippocrates

mentioned mania and melancholia in the fourth century B.C. By the first

century A.D. they were already coming to be regarded by many physicians

as part of one illness ; thus Aretaeus wrote that nlelancholia "is a low-

ness of the spirits without fever ; and it appears to me that melancholy

is the commencement and a part of mania." In the sixth century

Trallianus introduced the circular conception, which appears today in

874 PERSONALITY AND THE BEHAVIOR DISORDERS [29

the term "cycloid personality/' when he wrote of persons "not suffering

from melancholia only, for they tend to become maniacal periodically and

in a cycle" (Whitwell, 1936). General medical attitudes by the sixteenth

century were thus summed up by Jason Pratensis: "Most physicians

associate mania and melancholia as one disorder, because they consider

that they both have the same origin and cause, and differ only in degree

and manifestation ; others consider them to be quite distinct' 1 (Whitwell,

1936). Undeniably, many syndromes were then included under mania

and melancholia which today would be grouped with other psychoses

and neuroses. None the less, the modern tendency to look upon manias

and depressions as phases of one disease represents the continuation of

an old and established tradition.

Apparently the first persons to unite the two names to cover a single

syndrome were Bonet, who wrote in 1684 on folie maniac o-melanc clique

(i.e., manic-depressive insanity), Schacht, who in 1747 wrote on delirium

melancholic o-maniacum, and Herschel, who wrote in 1768 on morbis

melancholic o-maniacus. The French psychiatrist Falret senior intro-

duced the term folie circulaire in 1851. Three years later both he and

Baillarger published independently clinical descriptions of mania and

depression occurring in the same person. Falret's son in 1879 described

mixed states as transitional between mania and depression ; and Kahl-

baum in 1882 put the finishing touches by claiming that mania and

melancholia were always phases of a single disease.

The Present Situation. Kraepelin crystallized these attitudes in the

eighth edition of his remarkable four-volume textbook (1909-1913).

All severe depressions and all elated excitements became in his hands

only manifestations of a single phasic disease-process, of which excite-

ments were at one pole and depressions at the other. The widespread

official acceptance of this hypothesis has profoundly affected therapy

and research everywhere. Beneath the surface of this agreement for

clinical convenience, however, there lie innumerable unsolved problems

and some fundamental contradictions (Meyer, 1917; Partridge, 1931;

Oberndorf and Meyer, 1931; Rosanoff, 1938). Of these, Partridge

goes farthest in questioning the validity of any research reports that

compare groups, for example, of unselected manic-depressives with

groups of schizophrenics as though these were two relatively homo-

geneous disease entities. This criticism seems to have enough justifica-

tion, from both the biological and the psychological evidence, to throw

serious doubt upon the usefulness of a very large proportion of such

research data. The controversy has recently been summarized and its

relation to physiological and biochemical research reviewed by N.

Cameron (1942b).

The psychoanalytic school, beginning with the writings of Abraham

(1927) and Freud (1921), while introducing their own special con-

cepts, has deviated surprisingly little from the Kraepelinian position.

Glover (1932) and Klein (1935, 1940) show an increasing tendency to

29] THE FUNCTIONAL PSYCHOSES 875

oppose depression to paranoia rather than to mania, mainly on the basis

of adultomorph speculations upon the thinking of suckling babes. Rado

(1928), however, seems clearly to be attempting a fusion of Kraepelin

with psychoanalytical theory when he asserts that, "The manic condition

succeeds the phase of self-punishment [depression] with the same regu-

larity with which formerly, in the biological process, the bliss of satiety

succeeded to hunger."

Because of the many unsolved problems in this field the more doc-

trinaire and speculative attitudes will be avoided as much as possible.

In this way what facts there are may be presented as they actually

appear, rather than as they may have been interpreted according to one

or another system of postulates.

Mania.

HISTORICAL. Our conceptions of mania today have come from an

ancient distinction which sorted out from the excitements a group

neither accompanied by fever nor arising from the ingestion of toxic

substances. Aretaeus, for example, in the first century A.D. defined

mania as a continuous disorder of the mind without fever ; and he stated

definitely that deliria arising from the taking of specific substances should

not be included (Farrar, 1908; Jelliffe, 1931). He also wrote that

mania has recurrent periods and is curable ; his recognition of its relation

to depression has already been discussed. In modern times Kraepelin,

whose classificatory system is the model for most current schemes,

divided "manic states" into hypomania, mania, delusional forms, and

delirious forms (1908-1913). Under "mixed states" which, following

Falret fits, he regarded as transitional between mania and depression,

Kraepelin distinguished "depressive mania," "mania with poverty of

thought," "manic stupor," "angry mania," and "nagging mania." Of

these so-called mixed manic states only manic stupor seems to be sur-

viving in the literature. He also recognized "chronic mania," following

Schott (1904), whose classical descriptions have been reviewed in

English and added to by Wertham (1929).

The current trend is away from Kraepelin's tendency to make finer

and finer subdivisions, and toward a simple subgrouping on the basis

of severity into hypomania, acute mania, and delirious mania. Objections

have been raised to these terms because hypomania gets confused with

hypomanic personality, while delirious mania reintroduces a confusion

with toxic deliria which even the ancients were at great pains to avoid.

The writer suggests subacute mania r acute mania, and hyperacute mania

as simpler terms that cover the same categories. As for the other two

commonly used distinctions, the "manic stupor" is only a manic attack

in which the patient is mute ; while "chronic manias" are attacks of very

long duration and usually of mild or moderate intensity. The other

Kraepelinian varieties are little used and can largely be ignored.

DEFINITIONS. Mania may be defined as excitement in which the

person characteristically is elated and overactive without serious dis-

876 PERSONALITY AND THE BEHAVIOR DISORDERS [29

organization, and for which no underlying consistent physiopathology or

structural pathology has been demonstrated. Subacute mania ("hypo-

mania") is a mild degree of mania which shades imperceptibly into nor-

mal elated overactivity ; acute mania represents mania that has got

seriously out of hand; hyper acute mania ("delirious mania") is manic

excitement so severe as to involve serious disorientation and such ex-

treme overactivity as to endanger the patient's life. Mania character-

istically comes in attacks having a fairly definite beginning and end

(Harrowes, 193 la), but, like most other personality disorders, it may

have a long prodromal period and is subject to recurrence.

SUBACUTE MANIA ("HYPOMANIA"). Subacute mania may at first

appear to be only an episode of normal mild euphoria. Its onset may

date from a mere increase in elation or in general activity, or from a

shift to elation and a more active attitude in a person who is ordinarily

quiet and retiring. Thus to both the subject and his associates the

change is often taken to be an improvement ; and encouragement is

usually given him by his associates to continue along this direction of

development. Subacute mania may follow a depressive episode. The

typical early clinical appearance is often compared to that of mild alco-

holic intoxication ; the person becomes gay or aggressive, or both, is

often witty and jolly, relatively uninhibited in speech and general con-

duct, inclined to increased initiative without a corresponding increase

in effectiveness, more self-confident than usual and less concerned over

the risks involved in his plans and their execution. Sleep-loss, constipa-

tion, and weight-loss are common.

It may be difficult in practice to establish to others' satisfaction the

fact that the patient is not at this time completely well; for he feels

better than usual, he may really be enjoying himself, and he may show

none of the more obviously pathological features of a full blown mania.

None the less in this phase he often will, if not curbed, indulge in enter-

tainments and in enterprises, unwisely conceived and poorly thought

out, which may have disastrous consequences for his economic, social

or personal status. Usually his family and his close friends recognize

that there is a change in his personality, especially if he grows domi-

neering, sleepless and increasingly erotic. Often subacute manic attacks,

lasting several weeks, are successfully handled without hospitalization

and even without competent medical guidance; but the dangers to the

person's health, to his reputation and to his future are very real and

should never be ignored by those in any way responsible for his well-

being. The milder excitements may subside or go on after a period of a

few hours, days, or weeks into a more acute phase.

ACUTE MANIA. The intelligent layman, unless himself the patient,

can usually recognize the acute manic attack as definitely pathological.

The general picture one sees is that of a very excited, distractible, over-

active, overconfident, and continuously talkative person with whom

nevertheless rapport is usually good. There may be little or nothing in

29] THE FUNCTIONAL PSYCHOSES 877

his behavior that is incongruous with exaggerated and uninhibited ela-

tion. This is an important point because a very persistent tendency is

still present to consider every acute excitement, no matter how dis-

jointed and bizarre, as manic. The patient is restless, busy, impatient,

and sleepless; he feels little or no fatigue in spite of the extreme and

continual activity. He may sing loudly and gaily, shout himself hoarse,

prance about, do calisthenics, and even destroy things or injure other

persons in a spirit of anger, or as a demonstration of strength and

domination. Some manic persons become especially arrogant and abusive

to those in authority or to those who are responsible for curbing them.

The rapid flow of talk is typically peppered with quips, puns, rhymes,

and plays on words; there is a constant quick shifting from topic to

topic without, however, unintelligible gaps in continuity. Personal com-

ments, vulgar or obscene talk, and gestures are common. Many patients

engage in a great deal of writing, drawing, painting, or decorating ; and

these productions likewise are not, as a rule, bizarre or inexplicable to

the ordinary observer.

The very elated mood may shift easily to irritability, anger, and furi-

ous resentment if interference or restraint is arbitrarily introduced. It is

at this point often that, somewhat late for the patient's own good, in-

patient care in a psychiatric hospital is decided upon. The tendency of

manic patients to dominate situations, to interfere aggressively in others'

activities, and to engage in teasing, prankishness, and unbridled criticism

makes their separation from other patients often desirable ; their own

need for a nonstimulating neutral environment may make it practically

indispensable. At the same time bodily restraint, solitary confinement

without occupation or materials of any kind, and the imposition of rigid

discipline are unnecessary in a well-organized psychopathic hospital and

are fast disappearing from the modern treatment of acute mania.

In manic attacks the personal needs of the patient are frequently lost

sight of because of the ease with which manic conduct arouses anger,

ridicule or reprisal in those around. In spite of his uncontrolled clown-

ing, his facetious or obscene talk, and his almost complete lack of con-

sideration for others, the manic is often himself very sensitive, childishly

proud, and completely intolerant of criticism or ridicule. He benefits

from a friendly and tolerant atmosphere ; but he also needs, much more

than a normal person does, to be treated with a respect and consideration

which his own conduct does not automatically elicit. Diethelm (1936)

gives an unusually sympathetic picture of this aspect of the manic patient

based upon many years of clinical experience ; this work should be con-

sulted on questions of therapeutic handling.

Thinking disorders in the manic attack stem partly from the general

overactivity and from the elation and self-assertion. In addition to the

rapid shifting of topic and the distractibility already mentioned, there

rnay develop grandiose delusions of achievement, power or possessions.

The exact character of the delusive beliefs will naturally depend upon

the general personality, the past experiences and the present situation.

878 PERSONALITY AND THE BEHAVIOR DISORDERS [29

Expansive, powerful, important, and erotic roles are after all congruous

with elation and self-assertion. From unsuccessful or frustrated efforts

may also be derived delusions of interference, of malice or of persecution

by others. Hallucinations when present are transitory and relatively

unimportant. Religious or magical interpretations may intrude them-

selves into the picture ; but in the manic these are not dominant, nor are

they usually lasting. As in mild depressions talented persons may pro-

duce valuable artistic work related to their mood, so also in manic attacks

there may be productions of some value ; usually, however, the shifting

attention prevents completion of things even if well begun (Anastasi

and Foley, 1940, 1941a, 1941b, 1941c).

The acute manic person, even more than the subacute, needs special

attention to general hygiene and particularly to food intake and elimina-

tion. There is some confusion on this point. Abraham (1927) described

as typical of mania a patient in whom a ravenous appetite with gobbling

was prominent and evacuation very rapid. On this single observation he

built up a theory which still influences many current explanations (Rado,

1928; Glover, 1932; Fenichel, 1934; Klein, 1935, 1940). Actually it is

very often a difficult task to get manic patients to eat and to evacuate

adequately ; they are too busy and active to bother. If after some urging

the manic bolts his food, it is characteristically done in a hurry, as every-

thing else is, not eagerly and "cannibalistically" (Roheim, 1923), and

the patient turns at once to other things or uses the food for decoration

and play. Moreover, Henry (1931), on the basis of X-ray studies,

reported that gastrointestinal motility in acute mania is actually slower

than in the normal.

HYPERACUTE MANIA ("DELIRIOUS MANIA"). Acute manic attacks

occasionally develop to the point where the patient is wildly excited, dis-

oriented, and uncontrollable. His activity is continual, he is out of rap-

port, frequently hallucinates, grossly misinterprets events and mis-

identifies persons ; delusional material is common. Because of the grave

and often fatal consequences of such violent excitement, which throws

tremendous strain upon the cardiorespiratory system, hypercute mania

has been called in the past "delirium grave/' "collapse delirium," and

"typhomania." Something like it was described by Bell and it is still

often referred to as "Bell's mania." Kraines (1934) has reviewed its

history and described cases. It is questionable whether or not extreme

manic excitements deserve separate discussion ; certainly at their height

enough disorganization develops to make them nearly or quite indis-

tinguishable from any other wild excitement.

Depression.

HISTORICAL. The present-day attitudes toward melancholia or de-

pression, like those toward mania, have their origins in a more or less

continuous history reaching back into antiquity. Hippocrates, over 2,000

years ago, differentiated no less than six kinds of melancholia, some of

which apparently included clinical pictures that modern diagnosticians

29] THE FUNCTIONAL PSYCHOSES 879

would group with paranoia, schizophrenia, and the neuroses (Jeliffe,

1931). Aretaeus, in the first century A.D., defined melancholia as "a

lowness of spirits from a fixed and single fantasy, without fever"

(Farrar, 1908). From his clinical descriptions it is evident that he, too,

included syndromes that we would not call depressions today. Down

through the ages to the present there have been repeated discourses on

the nature, etiology, and treatment of melancholia. The last psychiatric

renaissance, beginning with the sweeping therapeutic reforms of Chiarugi,

Daquin, Pinel, Tuke, and others, ushered in a new era of clinical obser-

vation in the mental disorders, while the growth and dissemination of

medical periodicals made the reports and discussions of cases widely

accessible in Europe and America (Deutsch, 1937). One immediate

result was that the almost countless psychiatric syndromes until then

given separate status were reduced drastically in number, which greatly

simplified the task of those entering upon the study of mental disorder,

as, for example, in the system of J. P. Falret published in 1851 and 1854,

and that of Baillarger in 1854. The latter constructed a table showing

"the forms of mental diseases," in which he has listed four syndromes as

curable, viz., monomania, melancholia, mania, and insanity of double

form (presumably manic-depressive), and two syndromes as incurable,

viz., incoherent dementia and simple dementia. In addition he listed as

sometimes curable and sometimes not, delirium tremens, drug deliria,

and mental diseases associated with cerebral affections, including general

paresis, convulsive disorders, and local organic brain disease. As an

"appendix" he grouped imbecility and cretinism. During the latter half

of the nineteenth century there were gradually separated out a few

definite forms of depressive illness, largely through the work of Guislan,

Griesinger, and Kraft-Ebing, which led through the conceptions of

Kahlbaum and Hecker to Kraepelin's system (Jelliffe, 1931).

Kraepelin unintentionally wrote a clinical history of modern psy-

chiatry in the successive editions of his great textbook. He came to

differentiate six varieties of depression, viz., melancholia simplex, stupor,

melancholia gravis, paranoid melancholia, phantastic melancholia, and

delirious melancholia; and among the so-called "mixed states" he placed

depressed mania, agitated depression, depression with flight of ideas,

and partial inhibition. In his eighth edition (1909-1913) Kraepelin had

decided that most of the depressive syndromes, including involutional

melancholia to which he had in earlier editions given separate status,

were only parts of the single disease entity "manic-depressive insanity."

This decision was accepted by a committee of the American Psychiatric

Association in 1934 as final, and it was crystallized in an official classifi-

cation adopted first by the association and later by various state and

federal bureaus. A noteworthy exception was the exclusion of involu-

tional melancholia from this group and its quite premature inclusion

under "Psychoses due to disturbances of metabolism, nutrition or

endocrine function." The state and federal bureaus also followed the

association in listing separately, under the psychoneuroses, a "reactive

88o PERSONALITY AND THE BEHAVIOR DISORDERS [29

depression" supposedly different from the "endogenous" manic-depres-

sive disease in being situationally determined and responsive to psy-

chotherapy. The otherwise less adequate British official classification

(Fleming, 1933) rather wisely refused to commit itself on the as yet

unsettled etiology of involutional melancholia.

In what follows, three groups of depressions will be singled out for

discussion. Two of them, the retarded depression and the agitated or

anxious depression, are easily distinguishable syndromes. The third,

involutional melancholia, is the subject of so much controversy today

that for this reason alone it deserves special mention.

RETARDED DEPRESSION. Definitions. The retarded depression is a

condition of dejection and underactivity without serious disorganization

for which no underlying consistent physiopathology or structural pathol-

ogy has been demonstrated. The degrees of retarded depression custom-

arily distinguished are mild depression, marked or acute depression, and

depressive stupor. We shall follow the procedure adopted in the section

on mania by substituting for these, subacute, acute, and hyperacute re-

tarded depressions. Subacute retarded depression shades imperceptibly

over into normal discouragement; acute retarded depression represents

depression that has got seriously out of hand; hyperacute depression

("depressive stupor") refers to a degree so severe that the patient shows

almost no reaction to changes in his environment and in himself. Like

mania, retarded depression typically occurs in attacks having a fairly

definite beginning and ending ; usually attacks are preceded by prodromal

symptoms, often beginning months before the outbreak; occasionally

they are preceded by a frank manic episode.

Subacute Retarded Depression ( ( Mild Depression"). This may early

be indistinguishable in appearance from discouragement, malaise, or

fatigue. As time goes on without improvement, however, there is gen-

erally some recognition by others that the person is not up to par ; and

his associates may attempt to increase his activity through advice, enter-

tainment, and new environment. Sometimes such measures help the

patient for a while at least, sometimes they do not ; very often they only

increase his sense of inadequacy and make his depression worse.

Typically the person seems to grow sad and retiring, or irritable and

resentful. He loses interest and initiative, cannot see the light side of

life, has lost much of his usual self-confidence and self-assertion, and

his behavior, speech, and thought are slowed down. Sleep is poor,

constipation is the rule, and loss of appetite and weight usually appear.

It is quite possible to conceal subacute depressive episodes and pass

them off as ordinary fatigue, laziness, or worry. It is also common for

others to give them such a misinterpretation even in the face of frank

statements of hopelessness and gloom on the patient's part. The dangers

even in relatively mild depression may be very great. Suicide is an ever-

present threat which must never be discounted (Jameison and Wall,

1933 ; Jameison, 1936) ; associates of the depressed patient are much too

29] THE FUNCTIONAL PSYCHOSES 881

easily misled by his reassurances on this score. There is a wholly un-

founded belief that if a person repeatedly threatens suicide he will not

do it; this is a fatal error of judgment to make. There is also a real

possibility of homicide among depressed persons with dependents or

loved ones whom they picture as facing hopelessness, suffering, or

disaster with them. Only less severe are the dangers to health, business,

or family welfare, and to economic status arising from neglect, poor

judgment, or incompetence in a person still able to go on with his or her

routine. As with some subacute mania, it is often possible in the milder

retarded depressions to carry the patient over the depression without

hospitalization ; the far greater incidence of suicide in depressions, how-

ever, makes their treatment always a grave responsibility for the therapist,

who must be competent to recognize danger signals of all kinds (Diet-

hdm, 1936). A subacute episode may or may not usher in the acute

retarded depression.

Acute Retarded Depression. Even the acute depression may impress

others as only unusual worry, malaise, or inertia. Typically the person

is very slowed up and deeply dejected, with general behavior, speech,

and thinking difficult and monotonous. Initiative is conspicuously im-

paired. Lack of self-confidence and of self-assertion increases to hope-

lessness, and to severe self-disparagement and self-accusation. Expecta-

tion of punishment or of persecution is common. Sleep becomes

wretched, amounting often to only an hour or two in the twenty-four.

Appetite decreases markedly, becoming inadequate even for the now

greatly diminished level of general activity, so that weight falls off alarm-

ingly. Spoon-feeding and coaxing frequently become necessary ; and the

patient may have to be reminded to chew the food lying in his mouth

after he has admitted it. Some patients complain of difficulty in swal-

lowing food after mastication, which may be related to a reduction in

salivary secretion (Strongin and Hinsie, 1938). Complaints of dry

mouth, dry skin and hair are frequent, and they help along delusions of

body change.

Hypochondriacal complaints are usual and in some persons dominate

the picture (Ziegler, 1929), although these are generally more prominent

among the agitated than among the retarded. Delusions are common

and hallucinations also are reported (Bowman and Raymond, 193 la,

1931b; A. Lewis, 1934b). Sometimes nihilistic delusions referring espe-

cially to gastrointestinal function appear, most often in middle-aged

and elderly persons ; patients may insist they have no stomach or no

bowels, or that they have not had an evacuation for months. These

delusions are undoubtedly associated with the greatly slowed up gastroin-

testinal activity (Henry, 1931) and the digestive disturbances incident

to such malfunctioning.

In acute retarded depression it is the rule for the person to be

adversely affected by the urgings and expostulations of his associates

and advisers, who may still not recognize the change as an illness. His

efforts bring failure and this only emphasizes for him his actual inade-

882 PERSONALITY AND THE BEHAVIOR DISORDERS [29

quacy. The danger of suicide is very great, many acutely depressed

persons being unremitting in their plans and attempts at self-destruction

(Lendrum, 1933; Shapiro, 1935; Piker, 1938). The vigilance and

imagination necessary to prevent this all too common termination of

depression can be appreciated only through personal experience in the

treatment of it. Inevitably some of these continuously planned attempts

will be successful, even under expert psychiatric hospital treatment; but

the great majority of them can be prevented or, better still, avoided

through removing opportunities and providing helpful occupation and

competent psychotherapy. A recurrence severe enough to demand hos-

pital care occurs in about 50% of recovered cases (Pollock, 1931).

Hyperacute Retarded Depression ("Depressive Stupor"). In the

most extreme form of retarded depression, the person if left alone will

lie almost motionless and fail to respond to all attempts at establishing

or maintaining rapport. He will neither eat nor drink, and anything

placed in his mouth is likely to remain there until removed ; tube feed-

ing may then become necessary to preserve life. Evacuation often will

not occur without definite aid and this may have to be manual ; impac-

tions in neglected cases are common. Even lethal threats may be ignored.

It is, of course, very difficult and often impossible to differentiate de-

pressive from schizophrenic stupor on a phenomenological basis, since

both denote a state of profound unreactivity ; the previous and subse-

quent history provides the best basis.

There is a somewhat confusing use of the term depressive stupor to

cover also those cases of retarded depression in which patients who

although not so extremely depressed remain entirely mute. Diethelm

(1936) ascribes such mutism to fear and aversion. An interesting

account of what were taken to be "benign" stupors, i.e., functional

stupors with a good prognosis, was published in 1921 by Hoch. A

follow-up study of those of Hoch's cases still traceable was reported in

1935 by Rachlin, who found that the greater number had shown develop-

ments indistinguishable from catatonic stupors with an unfavorable out-

come. Gottlieb (1939) reported that rate of blood-flow seems to be

affected neither in mania nor in deep depressive stupor. The literature

on stupor has been reviewed by Mtmn (1933).

AGITATED AND ANXIOUS DEPRESSIONS. The agitated depression is

differentiated from the retarded depression on the basis of activity. In

both forms hopelessness, unworthiness, and self-accusation may be ex-

perienced, but whereas the retarded, depressed person is slowed up in

every respect, the agitated depressed is typically overactive and over-

talkative. He may be unable to remain in bed or in a chair, instead

pacing the floor, wringing his hands, moaning, or ejaculating phrases of

premonition and despair. Sleep, appetite, and weight suffer badly.

Usually there are numerous hypochondriacal complaints, probably asso-

ciated with the disruptions of normal functioning which the total clinical

picture includes. Delusional expectations of punishment, torture, and

29] THE FUNCTIONAL PSYCHOSES 883

public disgrace are very common. The need of these persons for pro-

tection from the stimulating or protesting environment of the home, as

well as from their own strongly impulsive suicidal attempts, is often

very great. Their need for simple occupation and encouragement is too

easily overlooked because any directive effort on their part appears to

the inexperienced to be entirely out of the question; but actually this is

a group that in the long run is very likely to repay every effort at con-

structive therapy made on the occupational level.

Falret fits in 1879 considered the agitated depression to be a mixed

state, part manic because overactive and part depressed for obvious

reasons. Such is the prevalent attitude today thanks to its adoption by

Kraepelin (1909-1913), whose decision in this respect was incorporated

into our official classification (Cheney, 1934). The logic of this posi-

tion is, however, not compelling. Overactivity and talkativeness do not

belong exclusively to mania, neither are they foreign to the normally

discouraged or apprehensive person. It is more useful and less confusing

to recognize under depression these variants, themselves counterparts

of normal variation, than it is to postulate equal parts of mania and of

melancholia mixed together in a human beaker to make an agitated

depression. The anxious depression may best be understood as a sub-

acute or mild degree of agitated depression.

INVOLUTIONAL MELANCHOLIA. According to the official American

classification, involutional melancholia includes depressions of middle

and later life characterized chiefly by agitation, uneasiness, sleeplessness

and often self-condemnatory trends, but without organic intellectual

defects. If these symptoms appear in a person who has ever in his life

had a previous attack of excitement or depression, however, his illness

is not to be classed as involutional melancholia but as manic-depressive

psychosis (Cheney, 1934). This contradictory exception illustrates par-

ticularly well the confusion in our classificatory attitudes. Henderson

and Gillespie (1940) consider involutional melancholia a fairly common

and definite illness whose essential features are anxiety, unreality feel-

ings, hypochondriacal or nihilistic delusions, and depression without

retardation, occurring in women between 40 and 55, and in men between

50 and 65 years of age. They acknowledge that the same syndrome may

occur in the twenties and thirties in women and before the fifth decade

in men ; and they go farther than the American classification in exclud-

ing all persons who have had any previous psychosis whatever, even

though they may have all these symptoms and also be within the involu-

tional period.

Hoch and MacCurdy (1922) felt it necessary to subdivide cases

usually called involutional melancholia into chronic and recoverable.

Among the chronic they separated off all those showing ridiculous delu-

sions, infantile sexuality, insufficient emotional reaction, and antisocial

conduct. These they regarded as cardinal symptoms of schizophrenia;

and they placed such cases in that group. Strecker and Ebaugh (1940),

884 PERSONALITY AND THE BEHAVIOR DISORDERS [29

however, consider that by restricting the age incidence to the involutional

period they eliminate schizophrenia as even a possibility. Hoch and

MacCurdy disposed of the rest of their chronic cases by calling them

"organic insufficiency" because they seemed to reflect a fundamental

and general senescence. They also eliminated any recoverable cases

showing typical retarded or agitated depressions, and all reactive depres-

sions when these happened to occur during the involutional period

regardless of past history. The group left, which they considered the

only genuine involutional melancholias, shows fears of impending death,

delusions of poverty and bodily disease, often with vivid hallucinations

and great agitation and restlessness, but otherwise without intellectual

impairment. MacCurdy (1925) explained away the occurrence of this

syndrome in young persons by making it depend upon "a certain type of

regression."

Meyer (1938) refers to "involutional psychoses" as including averse

and peevish depressions with judgment defects, less plastic and adequate

affective factors, and a tendency to rut-formation with an unfavorable

outcome. Diethelm (1936) emphasizes surliness and irritability, dis-

torted hypochondriacal delusions, untidiness, and often incontinence of

urine and stool. Henry (1938) stresses anxiety and restlessness, intensi-

fication of normal hypochondriasis, self-accusatory delusions, and a

striking ability to smile and be merry for brief periods. Jameison and

Wall (1931) conclude that involutional melancholia is in itself probably

not a complete clinical entity. General agreement as to clinical designa-

tion has not yet been reached.

Etiological problems in involutional melancholia are exaggerations of

those involved elsewhere among the functional psychoses. A few

workers take it for granted that failure of adequate sex hormone produc-

tion is the one important causal agent involved; others, like MacCurdy

(1925), use symptoms so strictly as criteria that young adults can be

included and the original age-period connotation is lost; while some,

like Pearson (1928), attempt psychoanalytic interpretations in terms

of libido regression. Titley (1936) reports "an almost constant pattern

of traits" that distinguishes the prepsychotic personality from those of

normal persons and of manic-depressives. From the hereditary stand-

point, Farr, Sloane, and Smith (1930) found significantly fewer cases

of "taint" among relatives of patients diagnosed involutional melan-

cholia than of the manic-depressive. Farrar and Franks (1931) discuss

the relationship between menopause and psychosis from several stand-

points.

One therapeutic test of the role of sex hormones is obviously that of

administering them to patients under controlled conditions. Although

details of treatment do not lie within the scope of this chapter, a brief

discussion of results of this method is in order. The reports in recent

papers are quite contradictory. Thus, while Werner, et al. (1936)

reported hormone therapy with theelin as curative in involutional melan-

cholia and even recommended its use as a test in differential diagnosis,

29] THE FUNCTIONAL PSYCHOSES 885

Schube, et al. (1937) found it of no value at all. In a second study,

Werner and his associates (Ault, Hoctor, and Werner, 1940) claimed

90% recoveries through sex hormone therapy and regarded shock

therapy unjustified unless estrogenic treatment had already been tried ;

and in 1941 they reasserted this general claim with additional support-

ing case material (Werner, Hoctor, and Ault). All this is contradicted

by the results obtained by Palmer, Hastings, and Sherman (1941), who

found estrogenic therapy of no avail while they credited metrazol shock

treatment with 73% recoveries or social remissions. Ripley, Shorr, and

Papanicolaou (1940) combined the experience of a clinical psychiatrist,

an internist, and an endocrinologist in a study of menopausal and post-

menopausal depressions. In this report, estrogenic hormone therapy

did not influence the patients' depression but only contributed to their

comfort through directly affecting vasomotor symptoms.

The involutional period of life involves many difficulties in addition

to endocrinological imbalance. There is a gradual decline in physical

vigor and health. Chronic illnesses in oneself, or in one's kin and friends,

grow commoner and call one's attention to the passage of time. The

realization of ambitions becomes obviously less likely. There is apt to

be less personal plasticity and less interest in new friends and new ad-

ventures. In women the loss of youth and the end of child-bearing, arid

in men the prospect of diminished powers and of retirement, undoubtedly

operate as etiological factors. Diethelm (1936) and Noyes (1939) give

considerable weight to these aspects. Billings (1939) considers involu-

tional melancholia as only an agitated depression that happens to fall in

the middle life-period.

MANIC-DEPRESSIVE CYCLES. A brief history of the development of

this concept has been included above. In the process of apparently re-

covering from a depressive attack a minority of persons go over into

mania, and a larger percentage goes from a manic illness over into de-

pression. This sequence has been recognized for at least 2,000 years;

there is no controversy about the fact of its occurrence. Two main ques-

tions may be mentioned. First, how long after apparent recovery from

depression may a manic attack occur and still be considered part of such

a cycle? The majority opinion and the official classification of the

English-speaking world maintain that there is no time limit. If any

person has a depressive attack and years later has an elated excitement,

these are considered to be two phases of a single disease. A minority

dissents from this opinion, maintaining that these are most usefully

treated as separate affective disorders in a susceptible person.

Secondly, suppose a person to have only one attack in his life of either

mania or depression. Officially, even if only one depression or one elated

excitement occurs in a life-time, such an attack must be considered as a

phase of the manic-depressive psychosis. The one official exception to

this ruling is the occurrence of an agitated depression after forty, which

is then to be considered as involutional melancholia and a thing apart

886 PERSONALITY AND THE BEHAVIOR DISORDERS [29

(Cheney, 1934; Fleming, 1934; Henderson and Gillespie, 1940). Any-

one having clinical experience with attacks of depression knows that

during the recovery period there may be a slight and transitory period

of overoptimism. According to the two-phase theory of affective dis-

orders this represents a small swing through the opposite phase and

therefore completes the cycle and corroborates the theory ; but an alter-

native interpretation is that it represents a mild overreaction to recovery

from a long and distressing illness in an emotionally reactive person.

Cameron (1942b) has suggested that manic attacks are not mere supple-

ments of depression but are coordinate affective disorders playing a

psychological role very similar to that of depressions ; and in this sense

they may be considered as depressive equivalents which often arise under

personal and situational conditions that correspond closely to those

giving rise to depressive attacks.

Bond and Partridge (1924), after analysis of 40 cases, concluded

that "the principle of unity that would make the phases of manic-

depressive reactions take their place as aspects of one fundamental psy-

chological or physiological process is wanting." They challenge assump-

tions that the small minority of patients showing alternate manic and

depressive attacks necessarily passes through a normal phase between;

they regard both as below the normal level. In the almost complete

absence of biological evidence for opposed physiological or biochemical

processes in mania and depression (Cameron, 1942b), their relationship

remains at least an open one. The importance of this to research workers

especially is that grave doubts are cast upon the validity of the prevalent

custom of comparing "manic-depressive patients" with "schizophrenic

patients" as though these represented well-defined and homogeneous

groups. Actually there are large variations in behavior and psycho-

pathology within each of these clinical groups so that such comparisons

become almost meaningless, unless careful selection within each group of

comparable and homogeneous material is carried out. A large part of the

work done in the past has probably been invalidated because of this

uncritical custom (Partridge, 1931).

Schizophrenia

Nowhere else in the field of psychopathology are there more funda-

mental problems for the clinician and the research worker, nowhere else

is there less agreement on so many important points than in schizo-

phrenia. The first common denominator that led up to the concept of this

functional psychosis was that of a deteriorating process, occurring in

young persons, which progressed to a demented end-stage, hence the obso-

lescent term dementia praccox. The first important revision of this basic

conception came when data accumulated showing that identical clinical

disturbances developed in persons who were in their thirties and forties.

The second important revision is now in progress. There is a growing

body of experimental and clinical evidence tending to discredit the

29] THE FUNCTIONAL PSYCHOSES 887

notion of a demented end-stage in all but a small minority of cases. The

answers to such questions as these problems not only help to shape our

theoretical structures but they determine just as much our whole thera-

peutic orientation. The present status of schizophrenia can become

intelligible only if its recent historical development is appreciated.

History. The early historical precursors of the modern concept of

schizophrenia are more difficult to identify than are those of the affec-

tive disorders. Such characteristic features as progressive apathy and

stupor, disorganized excitement and ecstasy, silly or incongruous be-

havior, and symbolic disorders of motility were easily confused with

manic and depressive attacks, or with phenomena similar in appearance

occurring in general systemic and in organic brain disease. On the side

of classification an important development immediately preceding the

contemporary era was that of the isolation and description by various

persons of four clinical groupings which Kraepelin then proceeded to

fuse into a single disease entity. One of these resembled paranoia in

having delusions as its most prominent constituent ; but unlike what was

then called "true paranoia," the delusions in these cases were poorly

systematized and there always appeared to be a tendency toward deteri-

oration. This group early received the name dementia paranoides.

Kahlbaum set up another group in 1868 which he called catatonia or

tension insanity ; he described it as a form of brain disease in which the

clinical pictures of melancholia, mania, stupor, confusion, and dementia

were supposed to follow upon one another. But the pathognomonic fea-

tures were characteristic disturbances of motility ; and these were said by

Kahlbaum to be just as specific for catatonia as other motility disturb-

ances were for paresis. His assumption of a basic structural brain disease

was made upon purely hypothetical grounds and has never been sub-

stantiated. A third clinical entity was put forward by Hecker in 1871

and named hebephrenia. According to Hecker, this was a progressive

disease of puberty and adolescence which began with a prodromal de-

pressive phase, went over into a silly, bizarre excitement, and then

terminated rapidly in a mental decline.

Hecker's hebephrenia was actually quite similar to a much older

group first described in England, and a century later in France ; it finally

got its name in Belgium, and this was then adopted in the Latinized

form, dementia praecox, by the Germans from whom the English-

speaking world received it again. The great English brain anatomist,

Willis, in 1674 described "young persons who, lively and spirited and at

times even brilliant in their childhood, passed into obtuseness and

hebetude during adolescence" (Meyer, 1928b). In the late eighteenth

and early nineteenth centuries Pinel and Esquirol gave similar descrip-

tions, the latter calling the condition "accidental or acquired idiocy,"

which he ascribed to unwise blood-letting, to head trauma, to masturba-

tion or the suppression of menses. In 1849 Connolly wrote, "Young per-

sons not infrequently fall into a state somewhat resembling melancholia,

888 PERSONALITY AND THE BEHAVIOR DISORDERS [29

without any discoverable cause of sorrow, and certainly without any

specific grief ; they become indolent or pursue their usual occupations or

recreations mechanically and without interest ; the intellect, the affections,

the passions, all seem inactive and the patients become utterly apathetic"

(Noyes, 1939).

It was the Belgian Morel who in 1860 introduced the term demence

precoce. He, too, emphasized the rapid decline of formerly talented or

precocious persons into dementia; but influenced by certain French and

Italian traditions he considered this an hereditary degenerative disease.

The term gained increasing currency until finally Kraepelin adopted it

as dementia praccox. He at first included it among the "degenerative

psychoses" ; and he considered it to be the same thing as Hecker's hebe-

phrenia but independent of, and coordinate with, Kahlbaum's catatonia

and the dementia paranoides. Later on, in line with contemporary

anatomical and metabolic theories, Kraepelin decided that these clinical

pictures together constituted a single unitary disease that was endogenous

rather than heredodegenerative in nature, and without recognizable en-

vironmental cause. To this whole disease entity he applied Morel's term,

dementia praecox, distinguishing hcbephrenic, paranoid, and catatonic

forms, and eventually adding a simple type also. This represents the

official and most widely accepted conception today.

Meanwhile there was a growing emphasis in other quarters upon per-

sonal and situational factors. The earlier work of Mesmer, Braid, Lie-

bault, and Charcot on hypnosis and suggestibility laid the foundation.

Toward the close of the last century there appeared in quick succession

Bernheim's book on suggestive therapeutics (1886), Janet's works on

psychological mechanisms (1889) and on the psychology of hysteria

(1893, 1894), and Breuer and Freud's studies in hysteria (1893, 1895).

Freud had gone to Paris in 1885 for a year with Charcot; and upon his

return to Vienna had translated some of his works and attempted to win

over his medical colleagues to Charcot's views. In 1889 he spent a

brief period studying with Bernheim in Nancy. Describing in their first

publication the method of arousing old memories, together with their

affect, and having the patient thoroughly talk out the recollections, Breuer

and Freud pointed out that, "In the interesting book of Janet, L'auto-

matisme psychologique, Paris, 1889, we find the description of a cure

brought about in an hysterical girl by a process similar to our method"

(1893). The importance of these cross-fertilizations for the problems of

schizophrenia cannot be overestimated.

The Present Situation. The modern era so far as schizophrenia is

concerned begins with the work of Bleuler in Switzerland (M. Bleuler,

1931) and of Adolf Meyer in the United States (Campbell, 1937;

Ebaugh, 1937). Bleuler ranks with Kraepelin in his thorough first-hand

mastery of clinical material, in his organization, and in his clear and

concise exposition. Psychologically he was an associationist and there-

fore ready for some of the psychoanalytic interpretations. He had already

29] THE FUNCTIONAL PSYCHOSES 889

(1906) published a monograph on the important role of emotion and

suggestibility in paranoia when he came into contact with Freud. He

was the first outstanding psychiatrist to recognize the value of psycho-

analytic emphases and urged the members of his hospital staff to master

Freud's theories. Some of Freud's most important disciples were re-

cruited from among Bleuler's assistants Jung, Abraham, Riklin, and

Brill. In 1908 Jung's study of the psychology of dementia praecox

appeared in which the influence of emotional factors or "complexes"

was illustrated by means of a word-association method adapted from

Galton and Wundt (Hunt, 1936). Abraham's theoretical paper contrast-

ing the emotional orientations in hysteria and in dementia praecox came

out the same year. In 1911 Freud brought out his analysis of the pub-

lished autobiography of a prominent paranoid schizophrenic patient, the

Schreber case.

In 1911 Bleuler's great work on schizophrenia also appeared, in which

he made this important and generous acknowledgment : "A great part

of the attempt to build up farther the pathology is nothing more than the

application of Freud's ideas on dementia praecox. I think every reader

will see without further comment how much we owe to this author,

even though I do not cite his name everywhere. I have further to thank

my colleagues in Burgholzli ; I name only Riklin, Abraham, and above

all Jung. It is not possible to distinguish what belongs to the observa-

tions and ideas of the one or the other among us" (1911). This mono-

graph and Bleuler's textbook (1930), first published in 1912, have had a

profound effect upon the attitudes of the whole psychiatric world. Al-

though always convinced that brain pathologists had satisfactorily demon-

strated characteristic cell changes for this illness, in spite of the mutually

contradictory nature of their reports, Bleuler nevertheless went a long

way toward developing the modern conception of schizophrenia as an

outcome of individual difficulties in personalities with many liabilities ;

and he continually emphasized on the basis of his own great clinical

experience the fact that social recoveries occur in schizophrenia.

The influence of Adolf Meyer's original and more nearly behavioral

approach (1906, 1910a, 1910b) has been mentioned; his dynamic con-

ception appeared independently of, and indeed prior to, the formulations

of Bleuler's staff. It has served as a basis for numerous interpretations

of schizophrenic disorders in this country that attempt to do justice

both to human biology and to the performance of the person in a

naturalistic environment. Variants of this approach may be found espe-

cially in Meyer (1934, 1938), Kanner (1935, 1940, 1942), Diethelm

(1936), Billings (1939), Muncie (1939). Meyer from the first has in-

sisted upon beginning the study of every patient by going directly to

whatever data can be obtained, starting always with the patient's own

complaints in their setting and their genetic order, and leaving interpre-

tations, inferences, and even technical terms until the end, then to be

used sparingly and with caution (1928a). Although this procedure has

long been accepted clinically and experimentally in other branches of

890 PERSONALITY AND THE BEHAVIOR DISORDERS [29

natural science, including medicine, the old rationalistic prejudices that

dominate psychology and psychopathology even today have conspired

with Meyer's difficult style of exposition to delay general adoption of

his eminently sound and naturalistic attitude. In many respects Meyer's

position in psychopathology is strikingly similar to that which James held

during the last decade of his life, in psychology (Cameron, 1942a).

Today when many well-trained psychiatrists, psychologists, sociologists,

and anthropologists are attacking the same problems in schizophrenia,

and with a degree of collaboration and mutual respect unheard of three

decades ago (Hoskins, et at., 1934; Hunt, 1936), the outlook for

broader and more empirical attitudes seems very promising.

Definitions and Symptomatology. The term schizophrenia (de-

mentia praecox) covers a large group of major personality disturbances

appearing commonly but not exclusively in adolescence and young adult-

hood, the most obvious characteristic of which is a disorganization of

thinking and doing, but with preservation of relatively good orientation

and memory. Following Meyer's account (1906, 1938), schizophrenic

reactions may be described as having in common "twists and fundamental

or fancy-born incongruities more or less foreign to average mature wak-

ing life," which develop often in tense, withdrawn or "shut-in" persons

who indulge in vague autistic fantasies, in empty ambitions with inade-

quacy of performance and false overcompensations, and a tendency to

ascribe their predicament to the malice or interference of other persons

or their machinations.

They see fancied meanings in the behavior of others. With disorgani-

zation of thought and the development of automatisms, the conviction

may appear that something is wrong in the atmosphere, that hypnotism is

being practiced or their minds being read, that they are being compelled

to do things and think things, that machines are being used on them or

that parts of their body are undergoing some kind of a strucural change

(Schilder, 1935; Angyal, 1935, 1936). Hetero-, homo-, and autoerotic

preoccupations are common. Religious-like dramatizations and episodes

of fantastic symbolic behavior often appear ; the apparent grotesqueness

of some delusional beliefs has virtually no limits. Hallucinatory experi-

ences are nowhere more common, except perhaps in disorienting deliria

and specific alcoholic hallucinoses. Schizophrenic hallucinations are most

often auditory, less often visual, olfactory, gustatory, tactile, and visceral.

The question as to whether these experiences are "genuine" hallucina-

tions or not is still being discussed (Campbell, 1930; Lundholm, 1931 ;

Gruhle, 1932b; Schilder, 1933; Hill, 1936).

There is often an inadequate blending of preference and aversion (am-

bivalence), with sudden unaccountable shifts in affection and hate some-

times leading to impulsive episodes. In many schizophrenics, at least on

the surface, the emotional reaction compared with the action may seem

strikingly incongruous (Stransky, 1903). Indifference and apathy are

frequent but not constant features.

29] THE FUNCTIONAL PSYCHOSES 891

Meyer emphasized the strange, odd, bizarre character of the activity ;

the staring, the posturing, and the mannerisms, often stereotyped; the

indecision, negativism, catalepsy, mutism, and stupor; and the com-

plaints of unnatural interference with and unaccountable interruptions

of thought (blocking). He describes talk as "scattered" or else verbiger-

ating (word salad), occasionally echolalic, and showing condensation.

Difficulty in understanding metaphors and proverbs in their derived

sense has been demonstrated by Frostig (1929), Hadlich (1931), Vigot-

sky (1934), Muncie (1937), and Wegrocki (1940). An extensive

review of the artistic productions of schizophrenics has been included in

the reports of Anastasi and Foley (1940, 1941a, 1941b, 1941c).

On the basis of studies of their behavior in situations requiring verbal

and manipulatory solutions, N. Cameron characterized the talk of dis-

organized schizophrenics as (1) asyndetic, i.e., lacking in essential con-

nectives; (2) metonymic, i.e., lacking in precise definitive terms for

which approximate but related terms or phrases are substituted (many

of these being personal idioms) ; and (3) interpenetrative, i.e., having

parts of one theme appearing as intrusive fragments in another unre-

lated theme (1938a, 1938b, 1939a). Their problem-solving in a group-

ing test brought out in both talk and manipulation (4) over inclusion,

i.e., environmental and imaginal material often only remotely related not

being eliminated from the problem; (5) frequent noncorrespondence be-

tween what the schizophrenics did and what they said about that which

they had done; (6) the calling for transformations in the rules of pro-

cedure and in the materials to justify failures; and (7) varied and shift-

ing verbal generalizations concerning solution hypotheses which were,

however, usually inadequate (1939b).

Quite apart from the problem of somatogenesis and psychogenesis,

already discussed, the question as to what psychological or behavior dis-

turbances are basic in schizophrenia has received many answers. Among

others may be mentioned regression to infantile narcissism (Freud,

1911) or to the level of primitive man (Storch, 1924; Werner, 1940) ;

habit deterioration (Meyer, 1906) ; reduction in association tension

(Bleuler, 1918) ; loss of thought-initiative (Gruhle, 1932a) ; reduction

in the range of attention and in central control (Beringer, 1926) ; in-

trapsychic ataxia (Stransky, 1903) ; agnosia and apraxia of thought

(Bychowski, 1935); overdevelopment of inner inhibition (Pavlov, in

Kasanin, 1932) ; loss of sustained effort and attention (Kendig and

Richmond, 1940) ; loss or impairment in abstract behavior and concept

formation with substitution of concrete behavior and perceptual thought

(Kleist, 1930; Vigotsky, 1934; Goldstein, 1939); social disarticulation

resulting from the cumulative replacement of communication by private

fantasy, in persons who have been unable to establish themselves firmly

in their cultural pattern, because of failure to develop adequate role-taking

skills (Cameron, 1938a, 1938b, 1939b, 1943b).

Some of these views take a definite stand on another significant ques-

tion for schizophrenia: (a) is there psychological continuity between the

892 PERSONALITY AND THE BEHAVIOR DISORDERS [29

normal and the frankly schizophrenic, or (b) is there a chasm between

them that cannot be bridged except at the structural level ? The weight

of authority is heavier on the side of the latter alternative (Kraepelin,

1909-1913; Jaspers, 1922; Kleist, 1930; Vigotsky, 1934; Bychowski,

1935; Goldstein, 1939; Hanfmann and Kasanin, 1942). Although the

hypothesis that in schizophrenia one drops from a conceptual or abstract

to a perceptual or concrete mode of thinking need not necessarily imply

the intervention of cerebral histopathology, in actuality the two assump-

tions usually go together.

The opposite view that normal behavior shades over into schizophrenic

without any essential chasm also has many advocates. Few today doubt

that there is continuity between normal and neurotic ; hence the common

occurrence of anxiety, hypochondria, and compulsive behavior as pre-

cursors or early symptoms of schizophrenia (Brown, 1940; Harrowes,

1931b; Miller, 1940) may be taken as another span in the bridge be-

tween the two extremes. The preoccupation of earlier workers with the

functioning of single organs and systems has been gradually shifting in

psychopathology to emphasis upon the performance of the total intact

organism. The writer believes that this theoretical progression must be

carried still farther to include not only the total organism but also the

social fields within which all human organisms operate.

The most recent studies indicate that heredity plays a relatively un-

important role in schizophrenic developments (Henry, 1938) ; the evi-

dence offered for an origin in organic brain disease has turned out, in

spite of recurrent positive claims, to be neither consistent nor acceptable

(Henry, 1938; Noyes, 1939) ; and no endocrine pathology has as yet

been established (Noyes, 1939; Henderson and Gillespie, 1940). The

changes involved in biological maturation during pubescent or adolescent

periods often play a very important role in directing and intensifying

certain urges, and particularly sexual ones ; but the prevailing emphases

today include more than this, recognizing the schizophrenias as a group

of habit disorders developing in persons who, because of emotional

and social maldevelopments and inadequacies, are especially susceptible

(Sullivan, 1927, 1929). Accordingly, neither a study of the immediately

precipitating situation nor of the person's constitutional make-up alone is

adequate ; nor can liberal interpretations in terms of the psychic life do

much more than push the problem out of the range of scientific and

clinical attack. To understand the etiology of a schizophrenic disorder in

a given person one must begin by mastering, as nearly as possible, his

particular life history.

CLASSIFICATION INTO SUBGROUPS. For convenience in description

and in hospital management, the schizophrenic disorders have been sub-

divided by the official American classification (Cheney, 1934) into Krae-

pelin's four types: the simple, the hebephrenic, the catatonic, and the

paranoid. The act of placing an individual schizophrenic reaction in one

of these subgroups signifies only that certain characteristics predominate

29 ] THE FUNCTIONAL PSYCHOSES 893

in the clinical picture ; it does not mean that the patient "has" this or that

disease-type. It is quite possible that during the illness the dominant

behavior characteristics will shift from those of one to those of another

subgroup. Also, the features of other subgroups are rarely if ever en-

tirely absent from any schizophrenic development taken in its entirety.

For instance, paranoid thinking is demonstrable in most schizophrenics

regardless of "type." Patients placed in the paranoid subgroup often

show "deterioration" and catatonic features. Hebephrenics also "de-

teriorate," express paranoid interpretations, and often assume catatonic

postures. Catatonics show these characteristics too ; and they may develop

the silly giggling or grimacing of hebephrenia. This overlapping will

be obvious in the account of the subgroups which follows.

These subgroups are much more easily distinguishable early in the

illness, in acute episodes or in those cases which reach a relatively sta-

tionary adjustment. If the disorder progresses very far, the patient's

social disarticulation grows, and the disorganization that follows may

lead toward similar behavior patterns almost regardless of the start.

It was this similarity of end-product in chronic cases that led the nine-

teenth century classifiers to ascribe the illness to biological degeneration.

SIMPLE TYPE (SIMPLE DETERIORATING; SCHIZOPHRENIA SIMPLEX).

This corresponds most closely to the descriptions of Willis in 1674 and

of Connolly in 1849, and to Morel's dcmence precoce (1860). The

patient gradually loses interest and, instead of increasing effectiveness

during adolescence and early adulthood, tends to decrease in his ability

to meet environmental demands. His unconcern and apathy at first are

seldom understood by those about him, and often not until his illness has

progressed a long way and for a long time ; then it is frequently too late

to expect adequate social recovery. Some persons, promising enough in

childhood, as they mature drift into simple clerical or manual work

where they make no progress and usually resist efforts to change or

complicate their routine. Many others become irresponsible idlers,

vagrants or prostitutes, or lead an asocial existence as neighborhood

eccentrics, apparently incapable of more than simple occupations.

The striking thing about the pathological development of those placed

in the simple group is that it is not marked by emotional outbursts, or by

strikingly peculiar behavior or obvious hallucinatory and delusional epi-

sodes. Like all negative diagnoses, however, this group is very apt in

practice to include persons whose early manifestations were simply not

noticed or not taken seriously by others, as well as persons whose secre-

tiveness in concealing hallucinatory and delusional episodes had been

unusually complete and successful. The more painstaking the anamnesis

by the physician is, and the greater the attempts carried out to contact

effectually the relatives and friends of patients placed in this group, the

smaller becomes the remnant finally left in it. Any number of hallu-

cinated and delusional patients are reported to the physician initially as

experiencing neither, both by the relatives with whom they have been

894 PERSONALITY AND THE BEHAVIOR DISORDERS [29

living and by themselves. The question as to the presence or absence of

delusions and hallucinations, either at the time of the original examina-

tion or in the past, can often be decided only after a close personal study.

In too many hospitals the psychiatric case load is so extremely heavy

(100-1,000 per physician), and in many active clinics the period of

stay is so brief for such a purpose (1-3 weeks), that even the most in-

terested and competently trained medical attendants lack the oppor-

tunity for adequate investigations. No factors are more responsible for

retarding the progress of psychopathology and psychiatry than the almost

universally inadequate provisions for medical, nursing, and research per-

sonnel in psychiatric hospitals and clinics.

HEBEPHRENIC TYPE. Officially this subgroup includes those schizo-

phrenic persons in whom silliness and incongruous or inappropriate

smiling and laughter are prominent (Kant, 1942), in whom bizarre

notions are expressed, neologisms are common (Domarus, 1924; Frostig,

1930; C. Schneider, 1930; Bryan, 1933), and hallucinations of a pleasant

sort predominate. This conception differs somewhat from Hecker's

original characterization (1871). The onset is insidious and usually

begins early in adolescence ; the delusions are vague, unsystematized, and

often fragmentary ; there often appear grimacing and odd symbolic man-

nerisms (Rosenzweig and Shakow, 1937). In these individuals any in-

terference with their fantasies or activities is apt to elicit sudden im-

pulsive retaliation ; often they become hostile and aggressive on the basis

of their belief that "influence machines'* or other semi-magical agents

are being used against them. Certain of these individuals become incon-

tinent and show a strong interest in urine and faeces, often using the

latter in smearing the walls or their persons. This activity and the silly,

incongruous antics are taken by some writers to be evidence of a return

to childhood; but in terms of clinical actualities, the behavior of the

hebephrenic bears little resemblance to that of a child. There is in some

quarters also a tendency to use hebephrenia as a "waste-basket diagnosis"

for those cases which do not fit into any one of the other three categories

(Noyes, 1939).

CATATONIC TYPE. In this subgroup are to be found schizophrenic

patients in whom motility disorders predominate, including phases of

stupor and of excitement, as well as the less dramatic reactions of pos-

turing, gesturing, and grimacing in repetitious, stereotyped behavior

patterns. The onset often appears in an acute attack which may be

precipitated by an obviously disturbing incident. Careful study of each

case, however, usually reveals other and earlier episodes which also

belong to the clinical development at least as premonitory signs e.g.,

increasing seclusiveness and loss of interest, preoccupation, fantasy, pas-

sivity and negativism, or else disorganized overactivity, reports of con-

version or of mystical experiences, fervor or ecstasy, and occasional ill-

conceived or impulsive attempts to cope with environmental demands.

Kahlbaum (1874), when he introduced this group, considered it to be a

29] THE FUNCTIONAL PSYCHOSES 895

degenerative disease of the central nervous system whose symptoms

could be accounted for by the location of supposed lesions. It is recog-

nized today, however, that these disorders are highly symbolic in char-

acter, and that the so-called automatism and negativism represent deep-

seated attitudes and responses on a personal basis. The behavior patterns

and the stream of talk in overactive catatonic patients, in spite of the dis-

organization, exhibit a variety of symbolic postures, gestures, and ex-

pressions not matched in other excitements (Homburger, 1932; Mayer-

Gross, 1932).

Catatonic mutism and stupor present many interesting psychological

problems (Coriat, 1909; Munn, 1934; Hunt, 1936; Last and Strom-

Olson, 1936; Darrow and Solomon, 1940; Cameron, 1941). Persons

mute for weeks or months may converse freely with a visitor, or sud-

denly ask for their physician, become fairly voluble for a time and then

lapse again into a protracted silence. The stupor in catatonic schizo-

phrenics is apt to be an active, not a passive, immobility. Attempts by

another to raise the patient's eyelids and to change the position of his

limbs or trunk usually meet with resistance. In spite of his evident lack

of reactivity, the stuporous patient may be quite observant. He is often,

for example, able afterwards to recall surprisingly well many events, and

even the names and utterances of medical attendants, belonging wholly

within the period of a prolonged and apparently continuous stupor. His

going into or coming out of stupor may be quite sudden ; sometimes in

response to an hallucinatory command a previously rigid, motionless

patient may suddenly attack a person violently and then relapse into

stupor.

Some of the phenomena usually associated with hypnosis also appear

in catatonics, e.g., heightened or greatly reduced suggestibility, changes

in reactions to pain (Grabfield, 1915; Bender and Schilder, 1930; Hus-

ton, 1934), catalepsy, etc. The occurrence of flexibilitas cerea in a hos-

pital provides a rough measure of the adequacy of the general treatment

of cases, its frequency being more or less inversely related to the psychi-

atric expertness of the staff (Diethelm, 1936). Landis, et al. (1934)

found that waxy flexibility in catatonia disappears during sleep. Landis

reported that normal college students during a fraternity initiation were

able to maintain fixed postures for periods of time comparable with

those seen in catatonia. Gaylor and Wishart (1933) found that when

postures were adopted by normals, in imitation of catatonics, their meta-

bolic rate was 20% greater than that of these catatonics. Landis, et al.

(1934) found, contrary to prominent hypotheses concerning the "fetal"

character of catatonic sleep, that actually they assumed "fetal postures'*

during sleep less frequently than did normals and in the waking state

more often.

PARANOID TYPE. When delusions dominate the clinical picture in a

schizophrenic development, the disorder is classed as paranoid schizo-

phrenia. The delusions are most often persecutory or grandiose in char-

896 PERSONALITY AND THE BEHAVIOR DISORDERS [29

acter, less often expansive or derogatory. Billings (1939) found that in

almost all his schizophrenic patients somatic complaints (often hypo-

chondriacal) were prominent, some of them delusional. Hemphill

(1939) has discussed the visceral etiology of certain somatic delusions

and Angyal (1935, 1936) attempts to demonstrate some mechanisms of

their origin. Paranoid delusions may at first be quite restricted in scope,

fairly logical and with congruent attitudes of resentment, aggression,

self-aggrandizement, anxiety, etc. Most observers agree that early in

the delusional development the personal wishes, needs, and fears are

often fairly obvious (Campbell, 1927) ; although Gruhle (1932b) denies

categorically that there is any such connection. With increasing disor-

ganization, however, the scope and variety of delusional topics increase

and for a time they become less stable and less logical. Vague mystical

and magical forces or influences appear, and their explanations grow

bizarre and fantastic. Ultimately, if the illness becomes chronic the delu-

sions may appear as stereotypes and lack adequate emotional participa-

tion ; then one sees other evidences of disorganization, such as scattering

or incoherence of speech, posturing, mannerisms and grimacing, a gen-

eralized suspiciousness and aloofness, or indifference and apathy. Hallu-

cinations, most often auditory, may be present from the beginning ; they

usually correspond in topic and mood with the delusional developments,

at least early in the illness. While the onset in the paranoid subgroup

is usually later than in the others, no age period seems to be exempt.

Resemblance of Psychotic Thinking to Dreaming and Fatigue

States. Psychotic thinking has been likened to normal dreaming and

hypnagogic states at least since the early nineteenth century, appearing

in the writings of Guislan, Moreau, and Griesinger. Pelletier (1903)

specifically compared the symbolism and thought sequences gathered

verbatim from dementia praecox patients with dreaming and, following

Masselon, attributed the product in both to attention disturbances.

Stransky (1903), Bleuler (1911), and in more recent years Beringer

(1924, 1926), C. Schneider (1925), and Mayer-Gross (1930) have made

the same comparison but with different data. Jung (1908) characterized

the schizophrenic as a dreaming man in an awake world, which Mayer-

Gross (1932) approves, but which Gruhle (1932b) rejects as greatly

overdrawn. Comparisons with the thought and speech of normal fatigued

persons have also been made (Kraepelin, 1906; Bumke, 1924).

C. Schneider believed that every schizophrenic phenomenon could be

understood in terms of the phenomena in fatigue and the hypnagogic and

hypnopompic states (1930).

Deterioration. We have seen that progressive intellectual deteri-

oration in dementia praecox was practically taken for granted up to the

turn of the century, and to the great majority this also meant progres-

sive brain deterioration. Meyer since 1906 has emphasized rather a

habit-deterioration and, himself a neuropathologist, the slenderness of

histological evidence of brain degeneration. Neisser (1909) called de-

29] THE FUNCTIONAL PSYCHOSES 897

terioration in dementia praecox only an appearance. While Kraepelin

(1909-1913) built up his disease entity on the assumption that all its

forms tend toward a deteriorated end-stage, he considered the dementia

mainly one of emotion and will, and only to a lesser extent of judgment

and memory ; he did not rule out the possibility of improvement even in

profound dementia. Gatewood (1909) ascribed his schizophrenics' in-

ferior performance in learning to their frequent shifts in method and a

loss of thought control. Ricksher (1909) noted that the degree of

dementia was apparently not related to duration of the illness, some old

chronic patients showing less deterioration in affect and less apathy than

more recent cases.

Bleuler (1911), under the influence of Freud and Jung, called atten-

tion to the selective character of the dementia both as to topic and as to

time, and the liability of a shift in the defect from one topic or activity

to another. For him the primary disturbances were in association and

affectivity (1918) ; where "clouding of consciousness" occurred, or where

disorders appeared in sensation, perception, memory, orientation, or even

in motility, Bleuler considered them secondary to other more funda-

mental processes. Apathy and reduced attention he ascribed to loss of

interest; and he, too, denied the inevitability of a genuinely demented

end-stage. The influence of associationistic psychology upon both Krae-

pelin and Bleuler is obvious ; their own influence upon current hypotheses

regarding schizophrenia is incalculably great.

According to Kent (1911) schizophrenics whom she regarded as very

deteriorated were still capable of learning new tasks. Cotton (1912),

using Kraepelin's method of continuous addition, found the performance

of schizophrenics only slightly inferior to that of his normal controls, and

this difference he attributed to disturbance of the will. Hart and Spear-

man (1914) investigated dementia praeccx by means of a number of

separate tasks and concluded that there was a diffuse generalized lower-

ing of intellectual level, for which they postulated an impairment in the

reinforcing or supporting function of the whole cerebral cortex. To

them, their results seemed to rule out specific defects in association,

judgment, concept-formation, memory, etc.; they considered the in-

equality in specific performance existing in normal subjects quite com-

parable with that found in psychotics.

Pressey (1917) using the Yerkes Point Scale found that schizo-

phrenics and alcoholics surpassed feebleminded subjects with the same

mental age rating in ability to define abstract words. Wells and Kelley

(1920) reported that schizophrenic patients showed little or no clear

reduction in intelligence ; they attribute the poor performance to apathy

and negativism and follow Kraepelin in regarding the basic defect to be

affective and volitional. Rawlings (1921), using tests of information,

association, genus-species, and the Yerkes-B ridges Point Scale, con-

siders reasoning and memory to be equally as impaired as the volitional

and affective functions.

Miihl (1922) observed that a mumbling, apparently confused and

898 PERSONALITY AND THE BEHAVIOR DISORDERS [29

demented schizophrenic could write down satisfactory answers to ques-

tions although unable to give them vocally. Mott (1922b) on the basis of

clinical and anatomical studies (1920a) characterized dementia praecox

as progressive and irreversible. Wentworth (1923), in a study of 200

schizophrenic patients, in which the Stanford-Binet was used, concluded

that intellectual deterioration occurred in only a small minority; she

corroborated Ricksher's findings that the degree of deterioration was not

directly related to duration of the illness in terms of hospitalization, and

accepted defective will and judgment as primary. The paranoid schizo-

phrenic patients tested by Barnes (1924) gave a performance on the

Stanford-Binet in 70% of the cases that was not below the level for the

general population. It is noteworthy that in the foregoing studies of

Pressey, Wells and Kelley, Wentworth, and Barnes there are no data

for normal controls run under comparable conditions. None of the

schizophrenics in a group studied by Davies (1926) fell below Terman's

"dull" level ; he found defects in memory and association but attributed

them to lack of interest incident to the emotional disturbances and their

consequences ; their loose thinking was noted but regarded merely as a

necessary economy.

Babcock (1930) attempted to set up an objective means of estimating

deterioration in schizophrenia through contrasting vocabulary age, which

she believed represented the prepsychotic level of intelligence, and the

performance on a variety of nonvocabulary tests ; she calls this differ-

ence score the efficiency index. Her assumptions are partly based upon

the high positive correlation found between vocabulary score, taken

alone, and the mental age on the Stanford-Binet scale for normal chil-

dren (Terman, 1919) and upon the results of work on psychotics re-

ported by Wells and Kelley (1920) in which the vocabulary tests of the

Binet were relatively well preserved. Babcock (1933) regards schizo-

phrenia as fundamentally a progressive deterioration on an organic basis

comparable to that in senile dementia. The studies of Schwarz (1932)

and Davidson (1937) in general support these results; Altman and

Shakow (1937) could not correlate the difference scores they obtained

with their own criteria of deterioration and concluded that it might result

from the schizophrenic thinking disorder. Wittmann (1933) was unable

to find evidence with the Babcock test for mental deterioration in schizo-

phrenia. Kendig and Richmond (1940) give a detailed and critical

evaluation of Babcock's investigations and conclusions on the basis of

their own work with 500 schizophrenic patients.

May (1931) considers intellectual deterioration so frequent and char-

acteristic an outcome as to justify a return to Kraepelin's conception

although he actually goes farther than Kraepelin ; he postulates "lack of

harmony between the intellect and the emotions and volition." Gruhle

(1932a) with at least as good reason insists that the intelligence of

schizophrenics remains intact. Vigotsky (1934) has no doubt that schizo-

phrenia is an organic deteriorative brain disease in which reduction from

conceptual thinking to associative thinking, or thinking in "complexes,"

29] THE FUNCTIONAL PSYCHOSES 899

although fundamental to emotional and other disturbances, is itself only

the outcome of central nervous system weakness and a loss in psychic

energy. "I am not at all inclined/' he writes, "to regard schizophrenia as

a psychogenic disorder." Harbinson (1936) followed the Babcock

method but substituted visual-perceptual tests of "G" ; according to his

criteria deterioration was found in about 30% of schizophrenics. Pio-

trowski (1937) made the interesting observations that schizophrenic

children seldom deteriorate in childhood and that they are inferior to

congenitally defective children in their approach and in their method

of handling concrete material. Trapp and James (1937) retested 41

patients to find the loss relatively small in paranoid schizophrenia but

large in the simple, hebephrenic, and catatonic types, results that were in

direct opposition to those of Kendig and Richmond (1940) with a com-

parable group. Gruhle (1932a) insists that both intelligence and speech

remain potentially intact in schizophrenics.

N. Cameron (1938b) made a qualitative comparative study of the

logical completion of 15 sentence fragments, each ending with because,

in 25 disorganized schizophrenics, 22 senile psychotics, 29 children, and

20 normal adults. The results fail to provide evidence that schizophrenic

disorganization yields a product in logical manipulations comparable to

that in senile deterioration or in normal children. The same disagree-

ment was also reported by Cameron (1939a, 1939b) between seniles and

schizophrenics both as to verbal and nonverbal behavior using the Ach-

Sakhorov technique; and he criticized the use of both regression and

deterioration to characterize schizophrenic disorganization. Partial re-

covery in one of the schizophrenics tested was accompanied by restitution

of normal logical forms (1938a). Malamud and Palmer (1938) com-

pared the performance on the Stanford-Binet in schizophrenia, in organic

psychoses, and in oligophrenia ; they were able to differentiate the groups

on the basis of patterns characteristic for each, the schizophrenic failing

most conspicuously where practical judgment is necessary.

The attitude of Darrah (1940) exemplifies a recommendation recur-

rent in the literature that we distinguish as schizophrenia a form with

sudden onset and negative family history that never deteriorates, and call

the deteriorating type dementia praecox. This plan ignores the lack of

agreement as to just what is deteriorated and whether the deterioration

is genuine, the difficulty in such an unstable population as ours of reason-

able certainty as to family histories, the innumerable unexpected im-

provements and recoveries from apparent deterioration and the equally

unexpected disorganization of persons after a decade or two of formally

correct and adequate behavior with only a few paranoid episodes.

Prophecy is nowhere more hazardous than in schizophrenia. Lehrman

(1940) in a study of 20 clinical cases concludes that neither is deteriora-

tion inevitable nor irreversible and recommends that the term deteri-

oration be reserved for organic cases. Similar conclusions may be drawn

from the results of chemical shock therapy (Zubin and Thompson, 1941)

and before that, from the results of injury, febrile illness, prolonged

9 oo PERSONALITY AND THE BEHAVIOR DISORDERS [29

narcosis, cold water shock and many other incidents (Deutsch, 1937;

Diethelm, 1939).

The report of Kendig and Richmond (1940) furnishes an historical

and critical evaluation of the whole problem. They studied performance

on the Stanford-Binet test of 500 cases of schizophrenia, 460 non-

schizophrenic hospital cases, 217 nurses and 129 other employees of St.

Elizabeth's Hospital. Although in general their schizophrenic patients

tested considerably below normal and showed an appreciable loss accord-

ing to the Babcock test, Kendig and Richmond found no evidence of

genuine intellectual deterioration and no selective impairment of particu-

lar functions of intelligence. On retest, patients showed no general

tendency on the test to an interim loss in adequacy. They believe that

emotional maladjustments beginning long before onset of the psychosis

render some of these persons progressively incapable of successful com-

petition and help precipitate the attack, while others perhaps begin with

poor native endowment and develop a schizophrenic picture for similar

reasons. Their schizophrenic patients failed most conspicuously in all

tests demanding sustained effort and attention ; upon the impairment in

these they place the blame for schizophrenic difficulties in selection and

in generalization. 1

Regression Hypothesis and "Levels" of Thinking. It is claimed

today in many quarters that schizophrenia represents regression to the

level of a child or of a primitive man. The comparison with the child

was implicit in the older accounts which held that the dementia of

adolescents was definitely an heredodegenerative disease bringing de-

velopment first to a standstill and then leading to a return to a childish

level. Variations of this hypothesis have played an important role in

interpretations of schizophrenia during the past three decades. It was

given special meaning and occupied an essential position in psycho-

analytic developments, where the regression was depicted as taking place

in the psyche (e.g., Freud, 1911 ; Abraham, 1916). Piaget (1923) placed

the thinking of the schizophrenic midway between the autistic thinking

of the child and the logical thinking of the normal adult. Parallels have

been drawn between schizophrenic symptoms and the behavior of the

normal child (Wildermuth, 1923). Gardner (1931) on a similar basis

attempted to equate psychotic symptoms with the behavior of normal

children in constructing a schedule from which a measure of regression,

called by him the "psychotic age," might be computed. However, studies

of the speech of normal children and of schizophrenics (McDonald, 1915 ;

Cameron, 1938b) and of normal preschool children with older schizo-

phrenic children (Despert, 1940) do not support the hypothesis. Pio-

trowski (1933a, 1933b) has shown that schizophrenic children differ

from defectives making the same test score in repeating errors less fre-

quently but also in failing to react to praise or to urging ; moreover, they

1 For further experimental results concerning this topic of deterioration, see

Chapter 32 by Hunt & Cofer.

29] THE FUNCTIONAL PSYCHOSES 901

do better on verbal tests than on performance tests whereas the opposite

is true of defectives.

Another form of regression hypothesis as applied to schizophrenia

developed partly under the influence of the older anthropologists (Levy-

Bruhl, 1923; Roheim, 1923). "Primitive" man, actually man in con-

temporary nontechnological civilizations, has been quite uncritically ac-

cepted as providing an accurate picture of any early stage in our own

biological and social evolution. This primitive man in common with

infrahuman animals was supposed, on purely a priori grounds, not to be

endowed with rationality but to be restricted in his thinking to simpler

perceptual complexes and pseudo-concepts. The child in our own con-

temporary technological civilizations was supposed also to think by means

of these subrational tools until pubescence when he somehow graduated

to conceptual thought.

These two forms of regression hypothesis have become inextricably

entangled in most presentations (Storch, 1924). In spite of the con-

trary evidence growing out of more recent advances in genetic psy-

chology and in anthropology, they are still applied to problems of

schizophrenic thinking essentially unaltered. In the clinical field, for

example, Levin (1930, 1931) treats both regression hypotheses as funda-

mental to an understanding of schizophrenia; Sprague (1940) does the

same for catatonia; and Osborne (1940) recommends our changing the

name of schizophrenia to palaeophrenia for this group of disorders. Kant

(1940) has introduced a three-fold personality stratification into somatic,

vital, and psychological levels within which schizophrenic changes are to

be comprehended.

Clinical, observational, and experimental investigations into the lan-

guage and thinking of schizophrenics are very numerous and only a few

can be considered here. The reviews of Bleuler (1911), Berze and

Gruhle (1929), C. Schneider (1930), Gruhle (1932b), Hunt (1936),

and Kendig and Richmond (1940) may be consulted. Rawlings (1921)

making use of the Yerkes-Bridges Point Scale and tests of association

and imagination found marked impairment of abstraction and general-

ization in schizophrenia with a tendency toward "concrete" rather than

"abstract" thinking. Piaget (1923) advanced the opinion, chiefly on the

basis of his work with children (1928, 1932), that schizophrenic logic

lay midway between the logic of normal prepubescent children and that

of the normal adult. Domarus (1923, 1927, 1929) arranged thinking

into prearchaic, archaic -paralogical, and paralogical-logical; the latter

two he considered to be typical of primitive savages and common in

schizophrenia, and the first as typical of man's anthropoid progenitors

and of schizophrenic stupor.

Storch (1924), stimulated by Freud's "Totem and Taboo" (1904)

and the hypotheses of Reiss (1921) and Kronfeld (1922), described

schizophrenic thinking as the outcome of a crumbling of the "rational

superstructure" which laid bare primitive archaic modes of dealing with

situations, and which substituted for conceptual thinking an inferior form

9 02 PERSONALITY AND THE BEHAVIOR DISORDERS [29

based upon concrete perceptual complexes. Wentworth (1923) using

the Stanford-Binet test found defective generalization in schizophrenics.

Kleist (1930) related schizophrenic disturbances to motor and sensory

aphasia. Vigotsky (1934, 1939), following Piaget (1923, 1928, 1932)

and Goldstein (1924; Gelb and Goldstein, 1925), on the basis of results

they obtained with the Ach-Sakharov test, concluded that children before

puberty are confined to concrete complexes, and only after puberty

develop genuine abstraction. While flatly rejecting the possibility of

psychogenic origins for schizophrenia, Vigotsky believed an impairment

in the function and formation of concepts to be "the most important

deterioration of thought occurring in schizophrenia." In connection with

the regression hypothesis, he declared that, "in ontogenesis complexes

precede concepts and actually form the inner layer on the old substruc-

ture beneath the new layers of concepts" (1934).

Bychowski (1935) reported defective categorization in his study of

schizophrenic logic, as well as a dropping out of concepts and inability

to retain an abstract attitude. He compared his results with those ob-

tained in organic defect cases by Goldstein (1924), Gelb and Goldstein

(1925) and Potzl (1928), and concluded that schizophrenic thinking

depends upon an agnosia and apraxia of thought. Meanwhile Bolles

(1937), following Gelb and Goldstein's approach to the study of organic

deficit reactions, compared the performance of schizophrenics with that

of oligophrenics and normal children. Normal children were able to give

responses "to objects as representatives of a class or category," whereas

both oligophrenics and schizophrenics were restricted to responses "pri-

marily determined by sensory impressions." The first of these she calls

"abstract behavior" and the second "concrete behavior." Her schizo-

phrenics were also unable to shift from one aspect of the problem situ-

ation to another when instructed to do so. Bolles and Goldstein (1938),

using similar technique and definitions, reported impairment of "abstract

behavior" in schizophrenia as well as difficulty in shifting attitudes and

in stating verbally why objects they grouped together seemed to belong

together. They concluded that the categorical attitude (Gelb and Gold-

stein, 1925), upon which they believe the use of true concepts depends,

is reduced or lost in schizophrenia.

Kasanin and Hanfmann (1938) followed Vigotsky's lead in using the

Ach-Sakharov test, and like him they found reduction or loss in con-

ceptual thinking and, like Bolles and Goldstein, loss of the categorical

attitude. Hanfmann (1939a) corroborated these findings in an intensive

study of one case. Shipley (1940a) has developed a vocabulary test on

the basis of which he derives an "abstraction age" and a "conceptual

quotient" (1940b) as indices of intellectual impairment. These and other

results have been critically summarized by Kendig and Richmond (1940)

and Hanfmann and Kasanin (1942).

Cameron (1938a, 1938b) studied schizophrenic logic by a method

similar to that used with normal children by Piaget (1928). Compari-

sons of these results with those obtained in the same task from normal

2 9 ] THE FUNCTIONAL PSYCHOSES 903

children and deteriorated seniles provided no support for regression

hypotheses. Diminishing social sharing and increasing preoccupation

in fantasy permit a functional impairment of communication and of other

forms of cooperative behavior, and a condition of social disarticulation

results (1939a, 1943b). Slotkin has recently reported examples of such

decay in social interactions (1941) ; while Despert (1940) failed to find

in normal children the confusion of reality and fantasy which Hanfmann

had reported for adult schizophrenics (1939b), but did find it in schizo-

phrenic children. Kendig and Richmond (1940) found in an extensive

study the performance of adult schizophrenics impaired, not selectively

in eductive or "abstract" tests, but in all tests requiring sustained atten-

tion and effort, "including those of memory and association/' Wegrocki's

experimental results (1940) contradicted both the dichotomy of thought

and the regressive hypothesis in relation to schizophrenics.

Cameron (1939b) later reported that, when adequate rapport and

cooperation had been established, even very disorganized schizophrenics

could be led to generalize rather freely and to shift their mode of attack

from one method or "category" to another. Although contrary to most

current reports, this is not an isolated observation. In fact Gatewood

(1909) found that shifting attitudes in memorizing problems were espe-

cially characteristic of schizophrenics; and Hunt (1936) has suggested

that this may help account for their relatively poor showing in recog-

nition and recall. Nevertheless, Hanfmann and Kasanin (1942) arbi-

trarily reject all the solutions which Cameron's schizophrenics offered,

based on shape, color, mass, weight, material, name, type, radius, angles,

opposition and equalization, apparently because these happen not to be

the particular generalizations demanded by the Ach-Sakharov test. In

effect, this is to say, "Unless you think of this problem the way I have

learned to, you are not generalizing at all !"

Goldstein and Scheerer (1941) deny that the schizophrenic can spon-

taneously evolve groupings according to material, form or color; but

Cameron's extremely disorganized schizophrenic patients with marked

asyndetic and metonymic thinking, both characteristic schizophrenic dis-

orders, did evolve such groupings using the Ach-Sakharov materials

and method, and quite without promptings or suggestions, as the verba-

tim shorthand records of his transactions plainly show (1939b). If one

accept Goldstein and Scheerer's criteria for the "abstract capacity level"

(1941), it is obvious to the writer on the basis not only of test situations

but of several years devoted to daily close communication with intelligent

schizophrenics of every degree of severity, that the "abstract capacity

level" can be found in most schizophrenics provided the painfully patient

technique necessary for effectual rapport with this group is developed.

Actually the criteria for the "abstract attitude" seem to be those cus-

tomarily employed in demonstrating the intervention of consciousness

which, the writer believes, have no more valid application in abnormal

than they have in normal behavior (see also interpretation in Chapter 32

by Hunt and Cofer).

904 PERSONALITY AND THE BEHAVIOR DISORDERS [29

There is good reason for doubting the usefulness, to say nothing of

the validity, of these determined efforts to maintain separate categories

of "abstract" and "concrete" behavior. The notion is based upon an

equally hypothetical differentiation between "perceptual" and "con-

ceptual" thinking; and upon inspection this will be found to reduce to

little more than the ancient narcissisiic flattery that granted rationality

to adult human thought but denied it to children and animals some

stoutly denied it to women also. The current form of this dichotomy is

grounded in certain nineteenth century evolutionary doctrines of ontog-

eny and phylogeny which, paradoxically enough, were originally de-

signed to establish not such breaks or chasms between species but an

essential continuity between the structure-functions of human beings and

other animals. The distinction between "abstract" and "concrete" atti-

tudes developed out of studies made upon aphasic patients with focal

lesions of cerebral structures; its transfer into the functional schizo-

phrenic field must be justified on a behavioral basis if it is to be justified

at all, since the evidence for focal lesions and even for genuine aphasia

is wanting, and the schizophrenic speech disorders very often fluctuate

between normal and unintelligibly pathological forms in relation to situ-

ational factors.

The fact that schizophrenic disorders do appear among adults in

"primitive" (i.e., nontechnological) civilizations and among young chil-

dren of our own contemporary technological civilizations, as well as the

results of comparisons that have been made between the logic of normal

children and adults and that of schizophrenics, contradicts the regression

hypotheses. Moreover, the contention is supported by the same evidence

that schizophrenic disorganization represents neither a retracing of the

ontogenetic-phylogenetic path of development, nor a removal of outer

layers of thought to expose any "primitive nucleus." Instead, it presents

us with a development, new and unique for a given individual's life his-

tory, that can be made quite intelligible in behavioral terms.

Paranoia

The term paranoia antedates Hippocrates ; but in ancient times it was

most frequently used in a very general sense, either to designate altered

or mad thinking which might occur in many disturbances, or even more

generally as the equivalent of our popular current term "insanity."

Paranoia practically disappeared from the medical literature with Celsus,

around the second century A.D., and did not reappear until Vogel picked

it up in the eighteenth century. Both Celsus and Vogel seem also to

have used it as the equivalent of insanity. The term enjoyed a short-

lived popularity in the eighteenth century as a class-name for delirious

and delusional disorders, only to be dropped again when Pinel reformed

and simplified the then florid Linnean nomenclature of psychiatry.

According to Jelliffe (1913), the roots of nineteenth century con-

troversies over paranoia, as well as of some contemporaneous attitudes,

29] THE FUNCTIONAL PSYCHOSES 905

are to be found in Heinroth's classification of 1818. In the spirit of

Kantian psychology, Heinroth divided "mental disturbances" into dis-

orders of the intellect, of the will and of the feelings. Exalted disturb-

ances of intellect he called paranoia, and of the feelings, paranoia ecstasia.

In addition he distinguished among intellectual disturbances three "mixed"

confusional states paranoia anomala or simple confusion, paranoia ano-

mala catholica or general confusion, and paranoia anomala maniaca or

confusion with furor. He introduced the terms "Wahnsinn" and "Ver-

rucktheit" which are still used in German psychiatry, the latter in Hein-

roth's sense, for paranoia.

One line of development from Heinroth has been relatively sterile ; it

culminated in the position of Ziehen, who early in our century still defined

paranoia in such a way as to embrace everything in which "primary"

delusions or hallucinations dominate, therefore most of the toxic-infec-

tious deliria as well as some hysterias, schizophrenias, etc. Griesinger

(1876) used Wahnsinn, as identical with paranoia ecstasia, to designate

a group of disorders in which expansive and often fantastic delusions and

hallucinations were prominent, and dementia the usual outcome. He

spoke of partial Verrucktheit, in which, and in his dementia, he grouped

patients who started off with an excited or depressed episode and slowly

developed a changed character with apathy, indifference, fixed delusions,

and usually hallucinations. It is obvious that most of these patients

would today be included among the schizophrenias.

After Kraepelin had set up his dementia praecox, with its four sub-

types, there was little left for paranoia. Kraepelin restricted the term to

chronically developing cases of intellectually produced, fixed delusions of

endogenous origin but without personality deterioration. Secondarily he

set up a provisional group supposed to be transitional between paranoia

and dementia praecox, the paraphrenias ; but they have not proved help-

ful and are little used (Henderson and Gillespie, 1940).

Freud (1896) made an exceedingly important step forward in describ-

ing a case of "chronic paranoia" as a defense psychosis and comparing

it with hysteria and obsessions. This marked the point of departure from

classificatory interests and Kantian psychology to a more dynamic pre-

occupation with the origin of symptoms. Freud postulated a gradual

weakening of defenses against repressed self-reproaches as part of the

paranoic process, resulting in their return to consciousness but now

ascribed to others in the form of delusions and hallucinations ; for this

development he introduced the term projection. Freud's analysis of the

Schreber autobiography (1911) also introduced the system of paradoxi-

cal denials and transformations by which homosexual wishes may give

rise to persecutory and grandiose delusions.

Meyer (1903, 1908) stressed the inability of paranoics to adapt the

trend of personal thoughts and their elaborations to the facts, their grow-

ing inclination to isolation, their excessive concern over what others

might think, their progressive failure to attempt real verification of sus-

picions, and their inadequate realization of a need for correction. In his

906 PERSONALITY AND THE BEHAVIOR DISORDERS [29

critical and historical review (1913) he includes material from Bjerre's

successful treatment of a case of paranoia of ten years' standing (Bjerre,

1912).

Bleuler (1906, 1926) worked out the relationship of affect to sug-

gestibility and of both these to paranoia. He considered paranoia to be

a purely psychogenic development occurring in certain kinds of persons

and not a "disease-process" as, it will be recalled, he regarded schizo-

phrenia. Bleuler ascribed the development in one person of hysteria and

in another of paranoia to a premorbid lability of mood in the former and

to excessive stability in the latter. He held that the errors and misinter-

pretations paranoics made were the same as those a normal person might

make under the same circumstances; the pathological feature was the

fixity of the errors, leading thus to delusions which, by expanding to

include more and more, ended up in paranoia. He opposed the still

prevalent doctrines that persecutory delusions come first, while self over-

evaluation and grandiose delusions are secondary and compensatory

outgrowths, or that persecutory are necessarily balanced by grandiose

delusions (Brown, 1940). For Bleuler, grandiosity was primary wish-

fulfilment, while persecutory delusions were always secondary processes

covering a conflict based upon unacknowledged incapacities.

Schulte (1924), writing from the Gestalt point of view, has inter-

preted self-reference as an attempt to fill in a chasm, between an indi-

vidual incapable of entering into "we-groups" and members of these

groups, by transforming the indifference of others toward him, even into

acts of criticism and hostility, provided only that by setting up a rela-

tionship the "wound is closed/' Kretschmer (1927) has attempted to

delineate a sensitive characterological type with tendencies toward self-

reference that tie up with paranoid and paranoic developments.

Brunswick (1929) presented interpretations of the dreams of a para-

noic woman, but her analysis shows considerable internal evidence of

indoctrination by the therapist. Kahn (1931) related paranoia and para-

noid states to the more active groups of eccentric psychopaths. Brill

(1934) and Knight (1940) have reviewed some of the evidence for the

often-found relationship between homoerotism and paranoia, the latter

stressing more the role of fear in strengthening persecutory delusions.

Cameron (1943a, 1943c) ascribes the genesis of both the sensitive asocial

personality and the paranoid delusions to a defective development of role-

taking in the individual, and to the relative inadequacy in social perspec-

tives that results. In place of the projection hypothesis he introduces the

concept of a pseudo-community, organized by the paranoic's reactions to

his own preoccupations out of fragments of the social behavior of others.

This view differs from its predecessors, also, in replacing the mind-body

or psychosomatic hypothesis of a double world by the simple interaction

between organismic and social behavior, from which can be derived per-

sonality development and maldevelopment. The literature on paranoia

has been reviewed by Meyer (1913), Bleuler (1926), Lange (1926),

and Kehrer (1928).

29 ] THE FUNCTIONAL PSYCHOSES 907

Definitions. In its most current use the term paranoia designates a

group of personality disorders, usually developing in the forties or fifties

(Dayton, 1940), characterized by fixed and systematized delusions in

the presence of formally correct conduct and good general grasp. There

is no striking tendency toward general personality disorganization ; and

while the course is usually very chronic and the outlook for complete

recovery is very poor, the development is not necessarily progressive;

the disorder often comes at some point to a standstill, or shows only

episodic flare-ups in an otherwise fairly well-adjusted life. No toxic sub-

stance or organic lesion has ever been implicated; in fact the paranoic

or paranoid episodes that so frequently occur in the course of systemic

disease, infection and intoxication are officially excluded from this group

(Cheney, 1934). Clinically, paranoia merges imperceptibly into paranoid

states (see below), into Kraepelin's paraphrenias (Henderson and Gil-

lespie, 1940), into paranoid schizophrenia, and into the sensitive paranoid

psychopath described by Kretschmer (1927). Even the classical cases

of Freud (1896, 1911) would be grouped by a large majority of psychi-

atrists today as belonging among the paranoid schizophrenics rather than

in paranoia without, however, detracting in the least from the value of

Freud's contributions to our understanding of paranoic thinking. Finally

other behavior disorders, whether of organic or of functional origin, often

show paranoic or paranoid characteristics ; but they are naturally classi-

fied according to the over-all picture.

Symptomatology. For a very long time it has been recognized that

certain personality characteristics favor the development of paranoia.

The predominant features of the development are, according to Meyer

(1903, 1908, 1913), an inability to adapt the personal trend of thought

and its elaboration to the facts and to make concessions or accept cor-

rections, while at the same time there are marked overconcern and sen-

sitiveness as to what others may be thinking. Early there are feelings

of uneasiness about the future and about what is going on, and a tend-

ency to brood and ruminate with increasing inclination toward isolation

from others. With ill-balanced aims and dissatisfactions there come sus-

picions and dominant notions about the intentions and goals of others.

Then to the actually indifferent actions of others, special meanings in

some personal relation to the patient are increasingly attributed, along

with a decrease in genuine attempts at verification of any conclusions

thus arrived at, and often with flat refusal to reconsider or discuss

the conclusions. The misinterpretations grow with the brooding and

fantasy, and become systematized while falsification of past incidents,

retrospectively considered, further distorts the train of events. The

excessive self-assertion of the person and his lack of adaptability make

it likely that antisocial and often violent reactions against others, who are

usually quite unaware of their danger, may occur without warning.

As Bleuler pointed out (1906, 1926), a discrepancy between exces-

sive ambition and relatively moderate ability sets the stage for para-

908 PERSONALITY AND THE BEHAVIOR DISORDERS [29

noic or paranoid developments in proud, sensitive, rigid persons who,

however, often utilize purely chance occurrences in building their delu-

sional systems, in the same way that normals often do in relation to

their pet beliefs. Freud (1911), in his analysis of Schreber's auto-

biography, posited a homosexual origin for all paranoid psychoses, with

the most-loved person of the same sex becoming the persecutor on the

basis of ambivalence. Freud demonstrated logically that when a patient

presents evidence of heterosexual fixation of delusions, it can still be

transformed, by the principle of opposites, into concealed homosexuality.

While the close relationship between sexual conflict and paranoic or

paranoid developments has now generally been accepted, Freud's drastic

restriction of its genesis to homosexuality or narcissistic repression has

not. The relatively common occurrence of paranoic or paranoid syn-

dromes among women of heterosexual interests during the thirties and

forties, when marital opportunities have dwindled or forbidden hetero-

sexual attachments have been developed, as well as their occurrence

somewhat later in heterosexual men with a very rigid moral code under

similar circumstances, seems to most psychiatrists to implicate other

sexual taboos. The influence of nonsexual factors, both personal in-

capacities and situational frustrations, must also be included in any

account of paranoic development (Kehrer, 1928; Noyes, 1939).

Meyer attributes special importance to the irresistible tendency of

paranoics toward systematization of experiences and false crystalliza-

tions, and to their retrospective falsifications and their sudden experi-

ences of matters becoming "all clear" to them. Bleuler, however, sees

nothing in paranoic developments that would not occur under the same

circumstances in a normal person, given a similar background. These

views do not seem irreconcilable.

The relationships claimed for grandiose and persecutory delusions

also presents psychological problems. Freud (1911) looked upon delu-

sional grandiosity as secondary to persecutory and as intended to pro-

vide an acceptable explanation of persecution to the patient; Brown

(1940), who accepts paranoia as regression to an anal level of reality-

testing, believes that the persecutory and grandiose represent balancing

sets of delusions which stabilize the disease and slow up its progress.

Bleuler (1926) and Diethelm (1936), on the other hand, consider

grandiose delusions to be direct compensatory developments related to

wish-fulfillment; Bleuler gives case illustrations of such developments

and of the existence side by side of grandiose and persecutory systems

showing no functional interdependence.

Both expansive and depressive episodes appear in paranoia, the

former giving it an elated, excited, angry or ecstatic coloring, sometimes

with hallucinations, and the latter a gloomy, sullen, unhappy, or hypo-

chondriacal character. Acute intercurrent exacerbations of the whole

delusional trend may alternate with relatively quiescent periods, a fact

that at one time engendered much nosological confusion when such

alternation was considered pathognomonic of the major affective dis-

29] THE FUNCTIONAL PSYCHOSES 909

orders. It was once customary to distinguish four and sometimes five

subvarieties of paranoia, e.g., persecutory, gradiose, erotic, litigious, or

querulous; but this custom has become obsolescent. Paranoia, as

described above, makes up only about 2% of first admissions to mental

hospitals (Landis and Page, 1938; Dayton, 1940). Kraepelin and

Bleuler reported that 70% of paranoics were men, but this is not sub-

stantiated by recent studies in this country. A report of the United

States Bureau of the Census shows only a negligible preponderance of

male over female paranoics among first admissions to mental hospitals

(Landis and Page, 1938) ; according to Dayton (1940), males made up

only 35% of those diagnosed paranoic among first admissions to

Massachusetts mental hospitals from 1917 to 1933. In part these are

only reflections of the lack of strict comparability with respect to the

diagnostic criteria employed by admitting officers.

Paranoid Conditions and Paranoid Personalities. Paranoia,

strictly speaking, may not be of very common occurrence but the num-

ber of persons in some way resembling paranoics is large. Wherever

evidence of general personality disorganization is found in such a case

it is considered to belong to the paranoid schizophrenic group. This

differentiation in practice is often very difficult to make and many psy-

chiatrists from Kraepelin on have considered throwing all paranoics

into the schizophrenic group ; but others have felt that the well-organized

and often intelligent and successful persons developing systematized

delusions deserve separate treatment. A very large group of sensitive,

rather rigid and difficult persons, with strong tendencies to self-reference,

is looked upon in many quarters as either potentially paranoic or already

partially paranoic or paranoid ; such persons, showing paranoic-like or

paranoid characteristics, are said to be in a paranoid condition or state.

Officially (Cheney, 1934) they are defined as having delusions, usually

persecutory in nature, and tendencies in the direction of misinterpreta-

tion and illogical thinking, sometimes too with hallucinations, but in any

case with little or no tendency to deteriorate. The distinction between

this and paranoid schizophrenia can be more easily made on paper than

with reference to a real patient ; and in practice it is actually not a very

important one to make unless, as is sometimes the case, therapy is

automatically determined by the diagnosis instead of being designed

according to the patient's problems. If one accept paranoid as going

with misinterpretation, illogical thinking and delusions, it is obvious that

almost all psychoses have paranoid ingredients. It is also evident that a

very large number of difficult persons, odd eccentrics, faddists, pseudo-

reformers, inventors, cantankerous and litigious men and women,

usually never seen by psychiatrists, falls legitimately into the group of

paranoid conditions or paranoid personalities, Kretschmer (1927),

Kehrer (1928), and Kahn (1931) have reviewed and discussed the

ramifications of this topic which is of considerable social importance.

9 io PERSONALITY AND THE BEHAVIOR DISORDERS [29

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29 ] THE FUNCTIONAL PSYCHOSES 921

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Chapter 30

THE CONCEPT OF PSYCHOPATHIC PERSONALITY

By PAUL WILLIAM PREU, M.D.

IT WOULD BE DESIRABLE to define "psychopathic personality" precisely

before undertaking to discuss the historical development of the term and

the implications of its use in present-day psychiatry. This logical pre-

liminary requirement for an orderly procedure is difficult to satisfy.

The diagnostic label psychopathic personality is a convenient designation,

as will be seen, in meeting certain practical necessities of psychiatric

practice ; but it is one of the vaguest terms employed in modern clinical

psychiatry. No agreement exists as to the exact limitations to be placed

on its use. Quotation of the definitions offered by leading authorities

will make plain the lack of definitive clarity :

Henderson and Gillespie (1930) : "Under the heading of constitu-

tional psychopathic inferiority we include persons who have been from

childhood or early youth habitually abnormal in their emotional reaction

and in their general behavior, but who do not reach except perhaps

episodically a degree of abnormality amounting to certifiable insanity,

and who show no intellectual defect" (p. 376).

Henry (1938) : "Instinctive and emotional deficiency are defects

found in large groups of individuals who are commonly referred to as

having psychopathic personalities or as representing constitutional psy-

chopathic inferiority. Such individuals are in frequent conflict with social

laws because of uncontrollable impulses to satisfy cravings of the present,

inability to profit by experience and lack of foresight. Many kinds and

degrees of deficiency occur" (p. 223).

Muncie (1939) : "The constitutional development disorders include,

in addition to the states of intellectual defect, the disorders of person-

ality structure showing disharmony or imbalance of the assets. There

may or may not also be intellectual limitation. These reactions constitute

the psychopathic personalities, also referred to as constitutional psycho-

pathic inferiorities. Since they are disorders of personality structure of

life-long duration, a great variety of types may be expected" (p. 197).

Strecker and Ebaugh (1940) : "In general, by the term constitutional

psychopathic inferior, we mean an individual who is ill-equipped from

birth to meet the demands of the environment. We feel that in true

psychopathic inferiority the primary consideration is a defect state. This

defect is not like that found in mental deficiency which involves primarily

the intellectual assets of the patient, but is a defect consisting of an

922

30] CONCEPT OF PSYCHOPATHIC PERSONALITY 923

apparent constitutional lack of responsiveness to the social demands of

honesty or truthfulness or decency or consideration of others and per-

haps chiefly in an inability to profit by experience" (p. 496).

These selected definitions represent the opinions of the majority of

psychiatrists concerning the meaning of psychopathic personality. They

may be comprehensively reformulated as follows :

The diagnostic labels psychopathic personality and constitutional psy-

chopathic inferiority designate those individuals who have manifested

considerable difficulty in social adjustment over a period of many years

or throughout life, but who are not of defective intelligence nor suffering

from structural disease of the brain or epilepsy, and whose difficulties in

adjustment have not been manifested by the behavioral syndromes which

are conventionally referred to as neuroses and psychoses.

The opinions of certain psychiatrists are not covered by this defini-

tion. Several dissenting points of view which are of special significance

will be considered subsequently. The comprehensive definition which is

offered is, however, a fair statement of the majority point of view and

therefore will serve as a convenient point of departure for the discussion

of the concept of psychopathic personality.

Historical Background

The development of the concept of psychopathic personality has been

reviewed by Partridge (1930) and more recently by Henderson (1939)

in his Salmon Memorial Lectures. Both accord priority to the English

psychiatrist Prichard (1835), who called the attention of the medical

profession to the existence of a large group of psychiatric problems not

covered by the conventional diagnosis of insanity as used at that time.

Prichard devised the terms "moral insanity" and "moral imbecility" to

designate this group of conditions, which are now generally classified

as psychopathic personality or constitutional psychopathic inferiority.

Quoting Prichard : "There is a form of mental derangement in which the

intellectual functions appear to have sustained little or no injury, while

the disorder is manifested principally or alone in the state of the feelings,

temper or habits. In cases of this nature the moral or active principles of

the mind are strangely perverted or depraved ; the power of self-govern-

ment is lost or greatly impaired and the individual is found to be in-

capable, not of talking or reasoning upon any subject proposed to him

but of conducting himself with decency and propriety in the business of

life."

The term "psychopathic inferiority" was introduced by Koch (1891),

who gave to it a broad connotation, employing it to designate not only

that group referred to by Prichard as morally insane but also certain

hysterical and obsessional neuroses. In the contribution of Koch there

appears for the first time the conception of an underlying fundamental

and presumably hereditarily determined weakness or inferiority pre-

disposing to psychopathic development.

924 PERSONALITY AND THE BEHAVIOR DISORDERS [30

Since the time of Koch psychopathic inferiority, or some term essen-

tially synonymous with it such as constitutional psychopathic inferiority,

constitutional psychopathic state, emotional instability, psychopathic state

and psychopathic inferiority, has been employed by the majority of psy-

chiatrists to indicate the presence of a definite personality problem,

or disorder, or illness which does not fit conveniently into any of the

established clinical categories.

The diagnosis has never been made dependent on the recognition of

particular symptoms or kinds of behavior in the direct descriptive sense,

nor on the demonstration of the operation of particular behavioral

dynamics, nor on the demonstration of the existence of any definite

etiologic factor. The emphasis has been predominantly but not exclu-

sively on the occurrence of social maladjustment, particularly on the

occurrence of persistent social maladjustment in the absence of the

symptoms of the traditional clinical entities of psychiatry.

No general agreement has been achieved on the permissible limits of

application of the label "psychopathic." The term has sometimes been

used broadly and sometimes employed more narrowly. Thus Kraepelin

(1915) included under the general heading of psychopathic personality

not only conditions of circumscribed inhibition of personality develop-

ment in the emotional and volitional spheres but also early and mild

stages of psychoses. He stated that in some instances it was a question

of choice whether to classify an individual as a psychopath or as neurotic.

Schneider (1923) limited the term to include only conditions of "con-

stitutional" defect other than intellectual deficiency.

Those who have attempted to differentiate subgroups within the

psychopathic have tended to use adjectives indicating that the problem

behavior qualitatively resembled that seen in the various mental "dis-

eases" but quantitatively stopped short of the full-blown picture. On

this basis have been elaborated such terms as schizoid, cycloid, and

epileptoid psychopathy.

Symptoms and Diagnostic Criteria

The scope and method of application as well as the etiologic implica-

tions of the diagnosis of psychopathic personality will be outlined in this

and in the following section in a way which it is felt portrays the present

consensus. The usage which appears to the reviewer to be typical or

average will be presented. It should be kept in mind that differences of

opinion between clinicians exist concerning nearly every point.

The diagnosis of psychopathic personality is customarily established

in the following way :

1. An individual who has given evidence of outspoken social mal-

adjustment is brought to the attention of the psychiatrist. A psychiatric

problem is assumed to be present since social maladjustment exists.

2. The diagnosis of psychopathic personality will be considered if the

maladjustment has been continuous or repeatedly recurrent over a long

30] CONCEPT OF PSYCHOPATHIC PERSONALITY 925

period of time, particularly if the problem behavior has proved resistant

to presumably adequate treatment.

3. The difficulty in adjustment may have been manifested by any

kind of symptom or behavioral pattern, provided that it has not been

manifested by symptoms clearly indicating defective intelligence, struc-

tural disease of the brain, epilepsy, the neuroses, manic-depressive psy-

chosis, or schizophrenia.

If those three criteria are satisfied, a definite diagnosis of psycho-

pathic personality will be made. It is obvious that this is diagnosis by

exclusion.

No special symptoms are considered to be specific or pathognomonic

of psychopathic personality. It is obvious, however, that symptoms of

some kind must be present or no psychiatric problem could be recog-

nized. It has already been stated that the symptoms of intellectual defect

and deterioration, and clouding of consciousness, as well as the familiar

syndromes of the established neurotic and psychotic descriptive entities

are arbitrarily excluded from consideration as evidence of psychopathy

(except, as will be shown presently, under special circumstances). It

follows, therefore, that the symptoms of psychopathy comprise all other

indications of maladjustment. Chief among these are the following:

1. Delinquency and law-breaking in general, including both minor

misdemeanors such as truancy, petty stealing, promiscuity and prostitu-

tion, as well as serious crimes such as larceny, forgery, and murder.

Delinquency of one kind or another constitutes the most frequently

utilized symptomatic basis for the diagnosis of psychopathic personality.

Not all delinquency is considered to be psychopathic but there is no

agreement as to just where the line of differentiation is to be drawn.

Various psychiatrists attempt to make distinction between isolated epi-

sodes of delinquency and repeated or habitual delinquency, between

delinquency which is understandable in terms of the biography of the

individual and that which is not, between compulsive delinquency and

that which lacks this quality, and between delinquency which is con-

sciously motivated and that which is motivated unconsciously. Such dis-

tinctions, needless to say, are not easy to make nor are they usually

very convincing.

2. Socially unconventional behavior which seriously interferes with

adjustment is also commonly accepted as evidence of psychopathy. Con-

spicuous lack of sociability may be mentioned here, as well as vaga-

bondage, litigiousness, and pathologic lying, together with a wide variety

of oddities and eccentricities, among them peculiar ways of dressing and

odd manners, unusual religious beliefs and extremist political and eco-

nomic opinions, especially if these latter are expressed with an attitude

of radical protest. It is of course admitted by all that it is difficult to

draw the line between the normal and the psychopathic in terms of social

conformity.

3. Emotional instability and other affective liabilities to comfortable

social adjustment also constitute a widely accepted basis for the symp-

926 PERSONALITY AND THE BEHAVIOR DISORDERS [30

tomatic diagnosis of psychopathy. Emotional instability is understood

to include emotional lability in general and conspicuous excitability in

particular as shown by the occurrence of poorly controlled and more or

less unpredictable emotional outbursts, especially with irritability and

aggressiveness. The individual with such symptoms is sometimes re-

ferred to as an epileptoid psychopath. Other affective symptoms of psy-

chopathy include habitual gloomy mood and the occurrence of frequent

swings of mood in the direction of depression or elation, the latter

characterizing the cycloid psychopath. It is not clear at what point the

distinction is to be made between psychopathic mood swings and manic-

depressive attacks.

4. Aberrant sexual behavior is considered by most psychiatrists to

be evidence of psychopathy but with many clinicians dissenting. In-

cluded here are homosexuality, sadism, masochism, and the rarer per-

versions as well as chronic masturbation.

5. Drug addiction and chronic alcoholism are usually considered

evidence of psychopathy, but here also there is much disagreement

between various psychiatrists.

The differential diagnosis between psychopathic personality and other

psychiatric diagnostic entities is made in a way which is often highly

arbitrary.

If outspoken, classical manic-depressive or schizophrenic symptoms

are present, a diagnosis of manic-depressive psychosis or schizophrenia

is made and not psychopathic personality. If the symptoms which sug-

gest a manic-depressive or schizophrenic condition are mild, a diagnosis

of psychopathic personality is usually made, sometimes with the quali-

fying adjective schizoid or cycloid. Most psychiatrists are reluctant to

make a definite diagnosis of manic-depressive psychosis or schizophrenia

unless the symptoms are unmistakable and the disorder severe. On the

few occasions in which both psychopathic personality and manic-depres-

sive psychosis or schizophrenia are diagnosed, it is commonly assumed

that the two conditions are separate and distinct, not that the psychosis

is an outgrowth or extension of the psychopathy even though the history

of the case indicates such a continuity of development.

Furthermore, an individual previously diagnosed as psychopathic is

reclassified as psychotic if outspoken manic-depressive or schizophrenic

symptoms develop, with the implication that the previous diagnosis of

psychopathic personality was incorrect. The diagnosis of epilepsy (or

convulsive state) will also be given precedence retrospectively and the

classification will be changed from psychopathic personality to epilepsy

if overt convulsive attacks develop or if electroencephalography reveals

cerebral dysrhythmia.

Finally, an individual previously classified as neurotic may be reclassi-

fied as psychopathic if the symptoms fail to subside or if social maladjust-

ment persists after presumably adequate treatment. The symptoms, it

should be emphasized, may have been perfectly typical of anxiety,

hysteria, or obsessional neurosis. None the less, treatment having failed,

30] CONCEPT OF PSYCHOPATHIC PERSONALITY 927

the patient is reclassified as an anxious, hysterical, or obsessional psycho-

path or a psychopathic personality with neurotic traits.

Etiologic Implications

Since Koch (1891) introduced the term "psychopathic inferiority"

the tendency has been to conceive of the basic difficulty as genetically

determined and to place the group designated as psychopathic in the

class of congenital defect states together with the intellectually defective

or feebleminded.

In recent years, many psychiatrists have abandoned the terms "psy-

chopathic inferiority" and "constitutional psychopathic inferiority" in

favor of the etiologically noncommittal labels of "psychopathic person-

ality" and "psychopathic state." Notwithstanding this, the psychopath

is still thought of by almost all psychiatrists as an individual born in some

way defective or at any rate hereditarily doomed to defective develop-

ment. Thus Henderson and Gillespie (1930), Henry (1938), Muncie

(1939), and Strecker and Ebaugh (1940) continue to classify the

psychopath in the group of constitutional defectives.

It should be noted that the adjective "constitutional," which so fre-

quently appears in the literature of psychopathy, is commonly under-

stood to refer to something which is genetically determined and not

acquired fortuitously or through the process of learning. A few psy-

chiatrists, notably Adolf Meyer, have attempted to use the term "con-

stitutional" in a broader sense to include not only those traits which are

genetically determined but also those which are acquired early and

thoroughly ingrained into the personality structure. This broadened

usage has not been generally accepted. Its appearance has added to the

confusion concerning the meaning of psychopathic personality.

Discussion of the Current Usage

The present status of the concept of psychopathic personality is

highly unsatisfactory.

It is evident that psychopathic personality is not a diagnostic entity

in the ordinary sense of the word. In the practice of all branches of

medicine, including psychiatry, the various disorders or clinical entities

or syndromes or reaction-types are recognized and differentiated in

terms of their symptoms and signs. General agreement exists that a

specific disease or clinical entity is to be diagnosed if a particular group

of symptoms and signs is present. The disease or clinical entity in ques-

tion, furthermore, is to be distinguished from others, which it may

superficially resemble, in terms of differences in symptoms or signs.

Having recognized and distinguished the specific disease or clinical entity

it is possible to proceed with a logical systematic study of its natural

course and its causes and to evaluate the relative efficiency of various

methods of treatment.

928 PERSONALITY AND THE BEHAVIOR DISORDERS [30

The diagnostic entities of psychiatry are not as clear cut or mutually

exclusive as those of internal medicine and surgery. Nevertheless quite

generally accepted symptomatic criteria have been established for the

various personality disturbances (intellectual defect, neuroses, and psy-

choses) with the exception of psychopathic personality. When an at-

tempt is made to pin down the diagnosis of psychopathic personality in

terms of pathognomonic symptoms it vanishes as a clinical entity.

No one symptom and no combination of symptoms which are de-

scribed as clinical manifestations of psychopathic personalit}' is specific

for that condition. Certainly delinquency, socially unconventional be-

havior, emotional instability, sexual aberration, and alcoholism are en-

countered in a great variety of personality disturbances. The more

general diagnostic criteria which have been proposed for psychopathy

are scarcely more satisfactory. The persistence of maladjustment for

many years or for a life-time, for example, does not distinguish psycho-

pathic personality from feeblemindedness or from many cases of schizo-

phrenia, anxiety, hysteria, and other neuroses. The psychopath is

sometimes described as an individual who, although of normal intelli-

gence, is incapable of learning by experience. The same might be said

of the chronic schizophrenic, the paranoid, and many so-called neurotics,

depending on the exact meanings assigned to the terms "intelligence"

and "learning by experience."

The conclusion seems warranted that psychopathic personality is not

a recognizable entity in the descriptive behavioral sense. The psycho-

pathic group includes an indefinite number of poorly delineated problems

of personality development and adjustment which do not happen to fit

conveniently into the accepted rigid system of psychiatric diagnosis.

What then is implied in the classification of an individual as a psycho-

path, if this procedure is not diagnosis in the ordinary sense? It is a

conclusion that the personality make-up of the individual differs from

the normal or average in the sense of having been in some vague way

originally defective or in being at any rate permanently warped or patho-

logic. The question of etiology is theoretically left open, but actually

psychopathic personality is conceived of by the majority of psychiatrists

as predominantly genetically determined.

The evidence for hereditary predisposition to psychopathic develop-

ment consists chiefly in the following observations :

1. Psychopathic maladjustment usually becomes evident in childhood.

Therefore it is probably hereditarily determined. Psychiatric experience,

however, clearly indicates that it is in the early years of childhood that

the forces of the social environment, especially as transmitted through

the family, exert the most powerful influence upon the development of

personality. Learned patterns of maladjustment would therefore be ex-

pected to become evident in the early years of life.

2. Psychopathic maladjustment, once established, continues to be

evident throughout the life of the individual. Therefore it must have an

30] CONCEPT OF PSYCHOPATHIC PERSONALITY 929

hereditary basis. But learned patterns of behavior, once thoroughly in-

grained, are well known to be so persistent.

3. Psychopathic maladjustment is often discernible in several mem-

bers of the same family group. It is concluded on this account that the

family stock is psychopath ically tainted. This argument again disregards

or at least greatly underestimates the importance of the attitudes oper-

ating within the family group in shaping the development of personality.

Any discussion of the inheritance of predisposition to the development

of personality traits or characteristics needs to be very specific if it is

to do justice to the facts. Such factors as intelligence and temperamental

make-up do seem to be genetically determined and not significantly

affected by learning. The same cannot be said of social attitudes, which

are best regarded as learned traits, granted that there must exist a

genetically determined potentiality for learning which varies both quanti-

tatively and qualitatively from one individual to another. It does violence

to common sense, however, and to accumulated experience with human

behavior to maintain that the occurrence of resentful asocial delinquency

in parent and child is evidence of innate predisposition to psychopathic

development. Such a statement is on a par with concluding that the

religiously bigoted child of a religiously bigoted parent has inherited a

predisposition to bigotry.

4. Psychopathic maladjustment is resistant to treatment, therefore

it is hereditarily determined. This conclusion is flattering to psychiatry

but is obviously fallacious, as any clinician can testify who has attempted

to treat such a typically learned pattern of maladjustment as hypochon-

driasis.

5. There is electroencephalographic evidence of cerebral pathophysi-

ology in certain psych opathically maladjusted children. This statement

is correct but is valid for an as yet undetermined percentage of so-called

psychopaths. The abnormalities in the electroencephalogram must be

correlated with specific patterns of maladjustment. It must not be for-

gotten furthermore that the majority of individuals with either electro-

encephalographic or overt manifestations of the convulsive state are not

socially maladjusted.

Finally, since psychopathic personality is not a recognizable specific

behavioral entity, the evaluation of the importance of hereditary factors

in its etiology resolves itself into a general discussion of the importance

of hereditary factors in the etiology of maladjustment and personality

disorder in general. That subject is treated in another section of this

book.

If the concept of psychopathic personality, as ordinarily understood,

is as unsatisfactory as has been indicated, it is necessary to consider the

reasons why it is still accepted by competent psychiatrists and so widely

utilized.

The main reason, in the opinion of the reviewer, is an increasingly

definite disagreement on the part of many psychiatrists with those

theories which seek to explain almost all psychiatric problems in terms

930 PERSONALITY AND THE BEHAVIOR DISORDERS [30

of environmental influences exclusively. The diagnosis of psychopathic

personality emphasizes this disagreement. It implies not only that some-

thing is wrong with the patient as well as with the environment but also

that the chief difficulty lies in the patient's personality make-up. Hender-

son (1939) has explicitly stated this.

To be consistent, however, those who feel the need for a term to call

attention to the liabilities in the personality itself should extend the con-

cept of psychopathic personality to include all personality disorders.

Manic-depressive psychosis and schizophrenia are in this broad sense as

definite evidence of psychopathy as are the types of maladjustment con-

ventionally diagnosed as psychopathic. Preu (1940) has outlined an

approach to psychiatric diagnosis on the basis of this broadened meaning

of psychopathic personality, utilizing the general conceptions of Kahn.

There are two other important reasons for the continued acceptance

and utilization of the concept of psychopathic personality which may not

be so obvious to the nonmedical student of personality disorders. The

clinical psychiatrist has to meet many urgent practical problems with

which the researcher does not have to concern himself. The clinician

finds the label diagnosis of psychopathic personality helpful in facing

certain of these problems of everyday clinical work, particularly in insti-

tutional practice and in the court.

The diagnosis of psychopathic personality is a convenience in the in-

stitutional practice of psychiatry. Many patients voluntarily enter or are

committed to psychiatric hospitals who obviously have disabling person-

ality problems or disorders but whose symptoms are not really classified

in terms of the more clear-cut established diagnostic categories. Psycho-

pathic personality satisfies the necessity which is felt to give each patient

a label diagnosis. The term at least indicates that a psychiatric problem

is present. Psychiatrists share with other physicians a reluctance to label

a patient "undiagnosed."

The diagnosis of psychopathic personality is also a convenience in

court practice where the psychiatrist is asked to express an opinion on

the question of responsibility. Psychopathic personality, in the forensic

situation, may readily be construed to constitute a mitigating state of

affairs, since it indicates that the individual is not fully responsible for

his actions although not wholly irresponsible or insane. Whether such

diagnostic procedure is jusifiable and socially desirable is open to debate

but need not be discussed here. The question has been ably reviewed by

Dession (1938).

Other Conceptions of Psychopathic Personality

It has already been mentioned that many individual differences of

opinion exist concerning various aspects of the concept of psychopathic

personality. It is neither necessary nor practical to consider a large

number of these, since most of them deviate only slightly from the con-

sensus with which the discussion has thus far been concerned. Three

30] CONCEPT OF PSYCHOPATHIC PERSONALITY 931

divergent points of view have been brought forward, however, which

deviate sufficiently from the consensus to necessitate separate con-

sideration.

The Contribution of Partridge

Partridge (1930) reviewed the literature on psychopathic person-

ality and concluded that disagreement on all points was so general that

the concept was in a state of confusion.

He maintained that the group diagnosed as psychopathic personality or

constitutional psychopathic inferiority was both descriptively and etiologi-

cally heterogeneous since it included intellectual deficiency and incipient,

mild, and atypical neuroses and psychoses as well as the subgroup which

he proposed to separate as the sociopathic.

Partridge suggested that a separate diagnostic entity called socio-

pathic be established, to rank coordinately with the neuroses and (func-

tional) psychoses as a definite, clearly recognizable pattern or kind of

maladjustment characterized by difficulty in adapting to the demands of

society as the central dominant issue or pathognomonic symptom.

The difficulties in delimiting the sociopathic group were apparent to

Partridge. He mentions, for example, the dynamic relationship between

the sociopathic (in his sense) and the paranoid. He believes, neverthe-

less, that if the issue of difficulty in adjusting to society as a whole is

made specific for the sociopathic such a diagnostic entity can be estab-

lished.

Partridge's suggestion is stimulating but its adoption would further

confuse the already unsatisfactory official system of psychiatric diagnosis.

At the present time two general kinds of diagnosis are made : the descrip-

tive, of which such categories as anxiety, depression, and schizophrenia

may be taken as examples, and the so-called etiological diagnoses, such

as psychosis with cerebral arteriosclerosis and psychosis with syphilitic

meningo-encephalitis, which state the issue in the terminology of internal

medicine and mention the personality problem only incidentally. The

adoption of the term "sociopathic" would introduce a third kind of diag-

nosis, the sociologic. This does not seem desirable. Psychiatry has roots

both in internal medicine, particularly neurology, and in sociology, but

it is not identical with either. The primary concern of psychiatry is the

pathology of the individual. Psychiatric diagnosis should therefore be

stated in terms of the functioning of the indivdual and not in terms which

are primarily either neurologic or sociologic.

The Contribution of Alexander

Alexander (1930) reviewed the question of the neurotic character.

This diagnostic term is the psychoanalytic label for the group usually

referred to as psychopathic personality. He maintained that the desig-

nation neurotic may be as accurately applied to the individual whose

difficulties manifest themselves in the form of a typical consistent pattern

932 PERSONALITY AND THE BEHAVIOR DISORDERS [30

of social behavior which is clearly a deviation from the normal as to the

individual who develops a circumscribed set of symptoms.

He set up four chief groups of psychopathologic reactions differen-

tiated in terms of psychoanalytic dynamics : neurosis, neurotic character,

psychosis, and true criminality. These groups are arranged in the order

of the decreasing ability of the ego to reject unconscious impulses, the

neurotic having the greatest capacity and the true criminal having none.

Alexander interpreted the dynamics of the four reactions as follows:

In neurosis, conflict is present. The unconscious impulses are dis-

placed and manifest themselves by means of substitutive gratification.

In neurotic character, conflict is also present but the unconscious im-

pulses manifest themseWes by means of neurotic acting out, achieving

true but disguised gratification.

In psychosis, conflict is absent, the defenses break down, and the ego

organization is destroyed. The unconscious impulses are gratified in an

undisguised fashion.

In true criminality conflict is also absent and defense also fails but

the ego organization is preserved. The unconscious impulses are unmodi-

fied and uninhibited.

Alexander's contention that the behavior of the psychopath is as neu-

rotic as is the behavior of the individuals conventionally diagnosed as

neurotic seems to the reviewer to be entirely correct. Whether one

accepts his dynamic interpretation depends upon whether one accepts

the psychoanalytic system of psychology.

The Contribution of Kahn

Eugen Kahn (1931) reformulated the concept of psychopathic per^

sonality. He makes no distinction between psychopathy and neurosis,

dealing with both under the general heading of psychopathic personality.

Kahn emphasizes that no sharp distinction can be made between the

normal and the psychopathic personality. The psychopath develops

symptoms or gets into social difficulty more readily than does the average

person. Social maladjustment is the crucial point in the practical diag-

nosis of psychopathy.

Clinical study of the psychopath reveals no personality components or

functions or traits which are not also found in the normal personality.

The difference between the two is quantitative. It is observed that in the

personality make-up of those individuals classified as psychopathic (on

the basis of social maladjustment) certain traits are disproportionately

developed in the sense of deficiency or exaggeration. This entails un-

evenness or disproportion in personality organization which makes

smooth functioning and successful environmental adjustment difficult.

The term "psychopathic," as used by Kahn, is therefore descriptive,

merely indicating inadequate personality functioning as judged by the

occurrence of social maladjustment. It has etiologic implications, how-

ever, since maladjustment is dealt with by Kahn essentially as a func-

3 o] CONCEPT OF PSYCHOPATHIC PERSONALITY 933

tion of a "pathologic" person and not as the response of a normal person

to a difficult environmental situation.

Kahn recognizes the importance of both genetic and environmental

influences in shaping the development of personality along psychopathic

lines. While warning against rigid etiologic interpretation in individual

cases of psychopathy, he leans toward a genetic interpretation of etiology

in the psychopathic group as a whole. His discussion of the etiology of

psychopathy is sufficiently liberal, however, to leave ample room for dif-

ference of opinion concerning causes.

Kahn conceives of the person as an indivisible biologic unit but for

purposes of expediency discusses personality in terms of its leading

aspects. These he designates as impulse, temperament, and character.

Impulse, in Kahn's sense, means drive, as manifested by the output of

energy. Impulse is genetically determined. Kahn discusses total impulse

(drive) quantitatively, noting the marked individual variations in output

of energy which justify the construction of the abstract types sthenic and

asthenic in terms of drive. He also discusses the individual impulses

(genetically determined patterns of energy output, drives, instincts), pay-

ing particular attention to the sex impulse. He discusses sexual devi-

ations at this point, maintaining that in some instances they are innate

impulsive anomalies and in others partly or predominantly determined by

social environmental influences.

Temperament is that aspect of personality which refers to the quality

of integrated functioning, the way in which behavior is objectively mani-

fested and subjectively experienced. It is concerned with personal func-

tioning in terms of speed of reactivity, tempo, smoothness, and diffuse

autonomic participation objectively and in terms of feeling-tone (affect)

subjectively. Temperament, like impulse, is genetically determined and

not learned.

Kahn discusses temperament in terms of the fundamental mood and

the reactive emotionality. The fundamental mood is the state of feeling-

tone characteristic of the individual. Outstanding differences may be

observed between individuals with respect to fundamental mood, in terms

of which abstract temperamental types may be constructed : the cheerful,

the gloomy, the anxious, the irritable, the colorless, and so forth. Some

individuals, the poikilothymic, are characterized by changeable or fluctu-

ating fundamental mood. The fundamental mood has far-reaching impli-

cations for environmental adjustment, since it imparts a specific coloring

to the way of experiencing which is characteristic of the individual. The

optimism of the cheerful, the pessimism of the gloomy, and the insecurity

of the anxious may be taken as examples. A correlation exists between

pyknic physique and cheerful, gloomy and poikilothymic fundamental

mood, and between leptosomic physique and a fundamental mood of

anxiety.

The tendency for the various fundamental moods to be associated

with certain other personality traits is noted, with definite implications

for social adjustment. Thus there is a tendency for cheerful mood to

934 PERSONALITY AND THE BEHAVIOR DISORDERS [30

be associated with vivaciousness, talkativeness, distractibility, and the

making of numerous but often superficial social contacts; for gloomy

mood to be associated with sluggishness and lack of sociability; for

anxious mood to be associated with immaturity and insecurity. The

social adjustment of the poikilothymic fluctuates with the swings of

mood. Outspoken cheerfulness, marked gloominess, and particularly the

cyclic variety of poikilothymic mood predispose to the development of

manic-depressive illnesses.

The reactive emotionality is that aspect of temperament which refers

to the threshold of affective excitability, the readiness with which affec-

tive responses are elicited by appropriate stimuli. Here again anti-

thetical abstract temperamental types may be constructed : the labile and

the phlegmatic, each with its implications for social adjustment.

Character is the third leading aspect of personality discussed by

Kahn. He uses the term to refer to the "directedness" of personality in

the sense of the tendency to strive toward goals. Character is mani-

fested in the complex system of attitudes maintained by the person

toward himself and toward other people, particularly as revealed in

specific interests and ambitions and other goal-determined patterns of

behavior.

The formation of character is the result of the impact of social en-

vironmental forces on the person. Since an individual may happen to be

born and to grow up in one environment or in another, the direction in

which character will develop is to a certain extent a matter of chance,

and unpredictable. Kahn stresses, however, that individuals vary con-

siderably on a genetic basis in their potentialities for characterologic de-

velopment. Impulse and temperament constitute the biologic foundation

for character.

The system of attitudes is scrutinized with respect to the relative de-

velopment of interest in self and of interest in others. The differences

which are evident between individuals in this respect permit the con-

struction of antithetical abstract characterologic types: the ego type,

characterized by ego-overvaluation, and the environmental type, charac-

terized by ego-undervaluation.

Definite ego-overvaluation may express itself as active autism in

which the individual ignores the needs of other people and ruthlessly

seeks power. This type of character typifies certain aggressive asocial

criminals. Or ego-overvaluation may take the form of egocentricity in

which the individual also more or less disregards the needs of others but

seeks prestige rather than power. Egocentricity typifies the hysterical

individual.

Definite ego-undervaluation likewise may express itself in either of

two ways. It may take the form of passive autism in which the indi-

vidual, feeling insecure in relation to other people, withdraws from con-

tact with them, often with resentment. Paranoid attitudes may be asso-

ciated. Or ego-undervaluation may express itself in the form of ego-

searching in which the individual, here also insecure in relation to others,

30] CONCEPT OF PSYCHOPATHIC PERSONALITY 935

establishes himself in a dependent, submissive relationship, often seeking

sympathy. Hypochondriacal behavior is frequently associated.

Kahn repeatedly emphasizes that the various types schematized in

terms of impulse, temperament, and character are pure abstractions

which are not to be applied literally to any individual. Various indi-

viduals simply show more or less resemblance to these abstractions.

Kahn discusses the various conventional neurotic and psychopathic

syndromes in terms of the basic aspects of personality previously out-

lined. Thus, sexual deviation is discussed chiefly in terms of impulse,

emotional-social instability chiefly in terms of impulse and temperament,

hypochondriasis chiefly in terms of impulse and character, and hysteria,

obsessive-compulsive neurosis, social eccentricity, and schizoid psycho-

pathy chiefly in terms of character. It is continually emphasized, how-

ever, that the total personality is involved in every pattern of adjust-

ment and in every clinical syndrome.

Kahn leaves open, in theory, the relative importance of genetic,

impersonal environmental factors (infection, trauma, and so forth) and

social environmental factors in the shaping of psychopathic personality

development. He personally leans toward a predominantly genetic inter-

pretation. He does not discuss intelligence as a fundamental leading

aspect of personality.

The general dynamics of psychopathic personality are discussed in

quantitative terms. The psychopathic personality is denned as one char-

acterized by quantitative peculiarities in impulse, temperament, and

character. These quantitative peculiarities result in a type of person-

ality structure which expresses itself socially in the form of maladjust-

ment. <

The point of view expressed by Kahn is an important contribution to

psychiatric theory. It puts the concept of psychopathic personality in

proper perspective against the background of general personality devel-

opment and organization. Kahn's approach to the study of personality

is biologically oriented and so broadly stated that it leaves ample room

for investigation and difference of opinion concerning causal factors

and the dynamics of personality development and symptom formation.

In the opinion of the reviewer, Kahn has so expanded the meaning of

psychopathy that the use of the term itself becomes superfluous. Inci-

dentally, Kahn's terminology does not readily lend itself to use in Amer-

ican institutional and court practice. This practical shortcoming, how-

ever, in no way diminishes the usefulness of his general theory in

psychiatric research.

Conclusion

The current points of view concerning psychopathic personality have

been outlined. The implications of the term, as used by the majority of

psychiatrists, have been discussed ; and three important divergent points

of view have been presented in contrast.

936 PERSONALITY AND THE BEHAVIOR DISORDERS [30

The term "psychopathic personality," as commonly understood, is

useless in psychiatric research. It is a diagnosis of convenience arrived

at by a process of exclusion. It does not refer to a specific behavioral

entity. It serves as a scrap-basket to which is relegated a group of

otherwise unclassified personality disorders and problems.

It is felt by some that the label psychopathic serves a useful practical

purpose in reminding psychiatrists that personality problems cannot be

explained in environmental terms exclusively. This hardly seems neces-

sary, but if it is, then the term should be applied to the neuroses and

psychoses as well as to the conditions now designated as psychopathic.

The value of the contributions of Partridge, Alexander, and Kahn is

best seen when they are evaluated independently rather than with refer-

ence to their bearing on the pseudo-entity psychopathic personality.

Partridge indicates the possibilities of a sociologically oriented approach

to psychiatric diagnosis. Alexander demonstrates that the kind of

behavior now generally referred to as psychopathic can readily be

interpreted as neurotic in psychoanalytic terms, thus rounding out the

psychoanalytic approach to general psychiatric diagnosis. Kahn offers a

biologically oriented approach to general personality development, adjust-

ment, and maladjustment which is the most comprehensive now extant.

It is impossible to do justice to these contributions by incidental refer-

ence and brief summary ; the original literature should be consulted.

The unsatisfactory state of the concept of psychopathic personality

illustrates the futility of orienting psychiatric research about the tradi-

tional clinical entities as "diseases" of nineteenth century psychiatry.

What is needed is a clear description of various problems of behavior

expressed in simple unambiguous language. It would thus be possible

to undertake a common sense attempt to specify the etiologic factors

without preconceived bias. Having done this, one could approach the

problems of prevention and treatment in a logical, systematic fashion.

BIBLIOGRAPHY

ALEXANDER, F. 1930. The neurotic character. Int. J. Psycho-Anal, 2, 292-311.

DESSION, G. H. 1938. Psychiatry and the conditioning of criminal justice. Yale

Law J., 47, 319-340.

HENDERSON, D. K. 1939. Psychopathic states. New York : Norton.

HENDERSON, D. K., & GILLESPIE, R. D. 1930. Textbook of psychiatry. (2nd ed.)

New York: Oxford Univ. Press.

HENRY, G. W. 1938. Essentials of psychiatry. (3rd ed.) Baltimore: Williams

& Wilkins.

JOSEPH, H. H., SOLOMON, P., & BRADLEY, C. 1938. Electroencephalographic analy-

sis of behavior problem children. Amer. J. Psychiat., 95, 641-658.

KAHN, E. 1931. Psychopathic personalities. New Haven: Yale University Press.

KOCH, J. L. A. 1891. Die Psychopathischen Minderwertigkeiten. Ravensburg:

Maier.

KRAEPELIN, E. 1915. Psychiatric. Vol. 4. (8th ed.) Part 3. Leipzig: Barth.

MUNCIE, W. 1939. Psychobiology and psychiatry. St. Louis: Mosby.

PARTRIDGE, G. E. 1930. Current conceptions of psychopathic personality. Amer.

J. Psychiat., 10, 53-99.

PREU, P. W. 1940. Psychopathic personalities. In Cyclopedia of medicine, sur-

gery and specialties. Philadelphia : Davis.

3 o] CONCEPT OF PSYCHOPATHIC PERSONALITY 937

PRICHARD, J. C. 1835. Treatise on insanity. London: Gilbert & Piper.

SCHNEIDER, K. 1923. Die psychopathischen Personlichkeiten. In Aschaffenburg,

Handbuch der Psychiatric. Leipzig- Wien : Deuticke.

STRECKER, E. A., & EBAUGH, F. G 1940. Practical clinical psychiatry. (Sth ed.)

Philadelphia : Blakiston,

Chapter 31

SEIZURE STATES

By WILLIAM G. LENNOX, M.D.

IN THE FIELD OF MEDICINE, the logical advance of knowledge is along

certain well-recognized lines. First is the accumulation of surface obser-

vations and symptoms ; second is the task of grouping those manifesta-

tions which seem to be related to one another and binding them together

by means of a name; third is the finding of the immediate cause or

causes of these apparently related phenomena; and fourth is the seem-

ingly visionary search for a final cause, which will explain not only a

single symptom complex but many apparently unrelated complexes.

This present discussion will deal mainly with certain seizure states

which have been more adequately studied and which have been shown

to possess a common constitutional or physiological basis. The attention

will be focused on epilepsy, migraine, fainting, and vaso-vagal attacks,

but I believe there are other borderland conditions, such as certain types

of psychoses, odd behavior, criminology, which future research may show

should be classified with the epilepsy-migraine group of seizure states.

Older clinicians have not been afraid to link diverse disease processes by

means of nomenclature. Thus, according to Liveing (1873), Trousseau

called tic douloureux and angina pectoris "epileptiform neuralgia." He

said that "mania transitoria" may follow or replace epileptic seizures.

Maudsley (1870) speaks of "furor transitorius" lasting a few hours or

days and comparable to a fit of epilepsy.

For purposes of orientation I shall first sketch the main features of

epilepsy and migraine, without attempting a detailed discussion and

documentation, for this will be found in the books by Lennox and Cobb

(1928) and by Lennox (1941). Shorter presentations appear in various

systems of medicine. Secondly, I shall give in some detail what is known

about the personality and behavior of epileptic and migrainous persons.

Epilepsy

Definition. Epilepsy is a recurrent disturbance in the chemico-

electrical activity of the brain which manifests itself in a symptom com-

plex of which impairment of consciousness, perturbation of the auto-

nomic nervous system, convulsive movements or psychic disturbances

are the essential components. Definitions may be based on the causes

of phenomena or on their manifestations. The above definition attempts

to include both. Strictly speaking, there may be asymptomatic as well

938

3i ] SEIZURE STATES 939

as symptomatic epilepsy. In the former case the person may have a

disturbance of discharging cells which shows itself in an abnormal

electroencephalographic tracing only.

Historical. Epilepsy is referred to in ancient Arabian, Egyptian,

and Hebrew writings. The most detailed early discussion of the condi-

tion is in the discussion commonly attributed to Hippocrates and dating

from about 400 B.C. This is a remarkable document for its common

sense and skilful discrediting of the term "sacred disease." The author

was a scientific-minded person who explained in detail the mechanism of

seizures, namely, the occlusion of the ventricles of the brain by moist

humors which interfered with the normal circulation through the brain.

In the centuries which surrounded the birth of Christ, Galen, Celsus,

Aretaeus of Cappadocia, and Avicenna had a good deal to say about

epilepsy. Writers of the middle ages, Guanerius, John of Gaddesden,

Bernard of Gordon, and Arnold of Villanova, gave more detailed direc-

tions about therapy but added nothing about the cause or mechanism of

seizures. Not until the Renaissance did medical writers look at patients

subject to seizures with their own eyes and begin to apply the newly

discovered facts of anatomy and physiology. Around the year 1700 ideas

began to stir. Old explanations of occluded ventricles and mechanical

traction on nerves were abandoned. Thomas Willis in England and

Hermann Boerhaave in Holland wrote extensively on the subject of

epilepsy, reporting cases and autopsy findings. The former likened the

seizure to an explosive charge of gunpowder. He stated that the final

cause of epilepsy is chemical, a conclusion which is fully upheld by

present-day investigators. In the middle of the nineteenth century,

physiologists like Fritsch and Hitzig, and clinicians like Hughlings

Jackson and Cowers studied the neurological pathways involved in

seizures and found at last a drug which had definite value in the control

of convulsive seizures. The modern period of investigation and research

may be dated from 1920, when an osteopathic practitioner advertised

the fact that complete abstinence from food tended to hold seizures in

abeyance. Following these observations have come modern studies in

blood chemistry and in electroencephalography.

Incidence. Information derived from the 1917 draft as well as from

the questioning of small samples of the population indicates that the

incidence of epilepsy in the United States is approximately .5%. (Obvi-

ously the word "approximately" must be stressed. In many cases seiz-

ures are concealed or overlooked. On the other hand, many persons who

have had seizures in the past have lost this symptom.) The incidence is

much greater among children than adults, because of the fact that either

the seizures or the persons who have them tend to disappear. Men and

women seem to be about equally affected.

Symptomatology. The symptoms which were mentioned under

Definition may occur in varying proportions in different patients and

94 o PERSONALITY AND THE BEHAVIOR DISORDERS [31

in the same patients at different times. For purposes of convenience

three main types of seizures have been recognized. There is no typical

epileptic fit. A seizure may vary all the way from a transient impair-

ment of consciousness which is so slight that it is not recognized either

by the patient or by a person observing him, to a convulsion of demoniac

fury.

AURA. A grand mal attack is preceded in about one-half of patients

by premonitory symptoms. These are various, consisting perhaps of a

sensation of dizziness or of discomfort in the abdomen or, in special

cases, a tingling or numbness in an extremity. A symptom which is

localized furnishes a valuable means of determining from what part of

the brain the seizure arises. The aura, which corresponds to the first

gust before a storm, usually lasts but a few seconds and may not even

give the patient time for preparing himself against the ensuing attack.

GRAND MAL. The outstanding phenomenon in this type of seizure is

excessive muscular activity. The patient loses consciousness, his muscles

become rigid, respiration is suspended, and he falls if not supported.

Because of the suspended respiration, the face becomes dusky, the color

clearing only with the return of air to the lungs which occurs when

movements,, instead of being rigid (tonic), become jerking (clonic).

After from one to several minutes, jerking movements may cease and the

patient gradually regain consciousness. He may have bitten his tongue

or have lost control of his sphincters. A convulsion if severe may be

succeeded by headache, vomiting, muscular soreness, and depression of

spirits. Convulsive attacks occur at variable intervals, some patients

having only one or two a year, others having many a day. Very rarely

one attack may succeed another without the patient regaining conscious-

ness between. This is called status epilepticus.

JACKSONIAN ATTACKS. A special form of grand mal convulsion

begins in an extremity and spreads toward the brain, the patient retain-

ing consciousness, but unable to stop the spasmodic movements. Jack-

sonian seizures when present point to the corresponding area of the

brain, the cells of which are discharging abnormally.

PETIT MAL. In this form of attack the predominant feature is the

loss of consciousness. This is transient, lasting only a few seconds.

Unconsciousness begins and ends abruptly. It may not be complete. It

is not followed by mental confusion, nor is it attended by more than

small twitching motions of the muscles about the eye or face at the rate

of approximately three a second. The seizures of petit mal recur with

great frequency, often many times a day and every day. They are espe-

cially frequent in girls. They appear predominantly at or near puberty,

are not usually attended by mental deterioration, and are not easily influ^

enced by drugs.

3 i] SEIZURE STATES 941

PSYCHIC EQUIVALENT SEIZURES. These may be called psychic seiz-

ures, psychic variants, or psychomotor seizures. The predominate symp-

tom is amnesia. Consciousness is lost, but activity is not suspended. The

person is out of contact with his environment. He may perform purpose-

ful acts, but is not subject to command and after the period of confusion

is over has no recollection of what took place. The seizures are longer

than petit mal, lasting from a fraction of a minute to hours or even days.

Muscular movements if present are tonic and not clonic. The patient's

body may rotate or become slightly rigid, but does not go through the

violent tonic-clonic sequence of the grand mal. Psychomotor attacks are

more frequent in men than in women and in adults than in children.

These three main seizure types may not be pure. A particular seizure

may be a combination of two types. Furthermore, nearly one-half of

patients have more than one type. Approximately one-half of patients

have only grand mal, 8% only petit mal, and \% only psychic seizures.

With or without another type of seizure, grand mal occurs in 90% of

patients, petit mal in 45% and psychic in 8%.

Chemical and Physiological Mechanism of Seizures. Ever since

the days of Hippocrates, men have known that seizures arise from a

disorder in the brain. Hippocrates was even aware that injury to one

side of the brain would cause convulsive movements of the opposite side

of the body. Much of the work of persons interested in the study of

epilepsy has been concerned with the pathway of transmission of these

discharges from the brain. Most profitable has been the electrical stimu-

lation of the brain of animals with observation of the resulting con-

vulsion. This work, initiated by Fritsch and Hitzig (1870), has been

elaborated in recent years. Hughlings Jackson made far-reaching con-

clusions based on close observations of patients who suffered localized

convulsions as a result of injury to the brain and who later came to

autopsy. In recent years laboratory experiments and clinical observa-

tions have been united in the operating room observations of neuro-

surgeons, especially Penfield and his coworkers (1937). Unfortunately,

in patients electrical stimulation of the brain must usually be confined to

its surface. The relative strength of current required to produce con-

vulsions when various regions of the brain are stimulated has been

studied by Gibbs and Gibbs (1936). Curiously enough, the motor cortex

does not have as low a threshold as certain subcortical areas, especially

the region anterior to the thalamus. A yet finer means of study is that

of Dusser de Barenne and his associates (1937, 1938), who have mapped

the functional pathways of the brain not by observing the actions of the

animal but by following the spread of electrical patterns through the

brain, a procedure made possible by the electroencephalograph.

These studies permit a great extension of our knowledge concerning

the nervous pathways which induced impulses follow. They do not dis-

close the place of origin of seizures which arise spontaneously. Because

the clinical manifestations of a seizure in a given individual may vary

942 PERSONALITY AND THE BEHAVIOR DISORDERS [31

all the way from transient loss of consciousness to a generalized con-

vulsion, presumably the same area of the brain is not always involved,

even though the pathological lesion is constant. If the seizure is a

Jacksonian one involving, say, the right hand and arrn, with coincident

aphasia, the origin and pathway of spread of the discharge is obvious.

Seizures which are preceded by hallucinations of sound, taste, or odor

are often associated with tumor or other lesion in the temporal lobe.

But what of the petit mal seizures distinguished by only a rhythmic

twitching of eyebrows or a fixed upward gaze? Where does the gen-

eralized tonic-clonic convulsion arise? The electroencephalogram indi-

cates that in a great majority of cases abnormal discharges appear

simultaneously over the whole surface of the brain. Whether the dis-

charge is initiated simultaneously over the cortex or whether it spreads

to the cortex from a subcortical center cannot be told until someone has

the boldness to place electrodes in subcortical areas of the brain of

patients having frequent seizures.

Recent work has supported the contention of Hughlings Jackson that

epilepsy is an abnormal discharge of neurones of the brain. A far more

subtle and significant question is, what causes this abnormal discharge?

The solution of this question will involve knowledge of the electro-

chemical activity of discharging nervous cells. This peculiar type of dis-

charge which results in cortical dysrhythmia may be due to heredity or

environment or both. The fact that epilepsy may be hereditary has long

been recognized, but that disturbed electrical activity of the brain may

also be hereditary has been shown only recently by Lennox, Gibbs, and

Gibbs (1940). Presumably this disturbed activity is based on a peculiar

chemical make-up or reaction of nerve cells which is a transmissible

characteristic. Given some basic, constitutional and therefore continuous

abnormality, discontinuous environmental factors must also be postulated,

chemical changes which precipitate the unusual discharge which displays

itself in the form of clinical symptoms.

Electroencephalographic Findings. The results of electrical stud-

ies are of great significance for epilepsy and presumably for other con-

ditions associated with alterations of personality. A resume of the whole

subject of electroencephalography, with illustrative tracings and with a

complete bibliography of some 600 articles, is presented in the Atlas

recently written by Gibbs and Gibbs (1941). Electroencephalography

also is discussed in this book (Chapter 33 by Lindsley) so that only

aspects which bear directly on the subject of seizures will be dealt with

here.

1. Electroencephalographic records were made of patients at the time

they were having seizures by Berger (1929), who found a great com-

motion of waves at the time of attacks. Berger's observations with

epilepsy went little beyond this point, since his apparatus and his oppor-

tunities, as judged by present standards, were limited. Further observa-

tions reported by Gibbs, Davis, and Lennox (1935) showed additional

3 i] SEIZURE STATES

striking features, namely that during petit mal attacks the abnormality

consists of a high voltage alternate wave and spike occurring at the rate

of approximately three a second, the spike coinciding with the twitching

of facial muscles. Grand mal attacks are attended by an increase in the

speed and voltage of waves. Later on, Gibbs, Gibbs, and Lennox (1938)

observed that during psychomotor seizures characteristic waves were

also observed, these being abnormally large voltage slow waves at the

rate of from four to eight a second (see Fig. 1).

2. Gibbs, Davis, and Lennox (1935) discovered that abnormalities

might be present when patients were not displaying any symptoms.

Petit mal patients might show disturbances of rhythm which were in

reality very short or low voltage seizure discharges. Later it was found

that about 85% of patients with a history of seizures showed abnormali-

ties of rhythm in an interparoxysmal period, during a 20-minute period

of observation. (Patients with normal records are usually those having

rare seizures.) Dysrhythmia when present consists usually of bursts of

waves which are of increased voltage and either abnormally fast or

slow. If bursts of fast, spiky waves are present or there is the telltale

alternate wave and spike of petit mal, the patient usually has a history of

grand mal or of petit mal.

3. A certain proportion of normal persons, approximately IQ% in

samples so far taken by Gibbs and Gibbs (1941), exhibit abnormalities

which are similar to those encountered in patients who have a history of

seizures or a related condition. These persons might be called asymp-

tomatic or potential epileptics. Such a condition is not peculiar. Many

persons who have no cardiac symptoms can be shown by laboratory

methods to have disturbances in the rhythm of the heart. Many persons

^who are not diabetic have a high blood sugar curve. Individuals with

asymptomatic dysrhythmia outnumber those with seizures approximately

twenty to one. Presumably they form the reservoir out of which persons

with symptoms are recruited.

4. In some persons the electroencephalographic tracing if repeated

daily is of barometric value. An increase of abnormal waves may pre-

cede a seizure by many hours. Immediately before a grand nal attack

there is usually a speed-up of cortical activity with a decrease of voltage.

5. In most patients abnormal activity is present over all accessible

surfaces of the cerebrum. In a minority of patients the dysrhythmia

begins in one area and seems to spread to others. This is especially

likely to occur with patients who have a lesion of the brain in that area,

but characteristically persons who have no lesion (so-called idiopathic

epilepsy) display great variability from time to time. On one occasion

the abnormal waves may be more prominent in one area and on another

occasion in another area.

6. The effect of various drugs and changes of body physiology can

be shown in the electrical record. Sedatives used in the treatment of

patients bromides and phenobarbital cause a slowing of the cortical

frequencies. Opening or closing the eyes, going to sleep, changes in

944 PERSONALITY AND THE BEHAVIOR DISORDERS [31

GRAND MAL SEIZURE

HlGM VOLTAGE FAST WAVES

^/N-W^ V^irtMW^^^^

TONIC CLON , C

PETIT MAL SEIZURE

FAST WAVE AND SPiKE

f l200,

PETIT MAL VARIANT

SLOW WAVE AND SPIKE

PSYCHOMOTOR ATTACK

HIGH VOLTAGE SQUARE AND SIX PER SEC WAVES

-^vwvvw^^ /ui/yi/i^^

B I 8CC

I 1

Figure 1

Representative electroencephalograms of four patients to show records taken

before, and during, four different types of seizures, viz., grand mal, two forms of

petit mal, and psychic variant (psychomotor). At the right is the perpendicular

deflection made by a 50-millionth or 200-millionth volt current, and at the bottom

the time marked by one second. The left of each tracing is a portion of the person's

normal record. The rest of the tracing was made during a seizure. Four different

types of seizures are depicted. Uppermost is the tonic and then, after an interval,

the clonic phase of a grand mal convulsion. The second tracing is the three a

second alternate wave and spike of a petit mal. The third tracing is of the rela-

tively rare slow (two a second) wave and spike called petit mal variant. This is

not usually accompanied by symptoms. The fourth tracing was taken during two

phases of a psychomotor seizure. The tracings are about one-third their natural

size. (F. A. Gibbs, E. L. Gibbs, and W. G. Lennox, Archives of Neurology and

Psychiatry, Chicago, June, 1939, p. 1112)

3 ij SEIZURE STATES 945

r.ental activity influence abnormal as well as normal rhythms. The

alternate wave and spike formation of petit mal is especially susceptible

to changes in the concentration of carbon dioxide or sugar in the blood,

being precipitated by low concentrations and suppressed by high con-

centrations. Anoxemia if profound enough to cause unconsciousness

results in slowing.

7. In addition to the presence of dysrhythmia in a certain proportion

of normal individuals, a much larger proportion of persons who have

symptoms which are not ordinarily classed as epileptic may show dys-

rhythmia. Many problem children, as well as adults who show anti-

social tendencies, have abnormal records. This subject is discussed by

Lindsley (see Chapter 33). Also patients with psychosis may show

disturbances of rhythm. Davis and Davis (1939) reported that many

manic-depressive and schizophrenic patients have dysrhythmia, although

others have records grossly similar to those of normal individuals.

Other workers have reported somewhat similar findings.

8. The form of the brain wave seems to be a constitutional character-

istic of an individual. Observations on twins made by Davis and Davis

(1936) opened the door to a study cf the heredity of dysrhythmia.

Lennox, Gibbs, and Gibbs (1940 and unpublished observations) have

made electrical records of 70 pairs of twins and of 262 close relatives

of epileptic patients. Although the pattern of cortical brain waves is a

fluid and not a fixed characteristic, it is, these authors believe, an

hereditary trait. Of the 262 relatives, 53% had dysrhythmia. In 78

families records were obtained of both parents. In 27% both parents

had abnormal records, in 53% only one was definitely abnormal, in 10%

one parent's record was borderline, and in only 10% were the records

of both parents entirely normal. Confirmatory evidence has been sup-

plied by other workers.

There are 20 persons with cortical dysrhythmia for each person with

epilepsy. Presumably the great majority of these normal but dys-

rhythmic individuals carry a predisposition towards epilepsy or an

allied disorder.

A question of moment is, "What are these allied dysrhythmic dis-

orders and can their heredity be traced by means of the electroencephalo-

gram?" Thoughts go immediately to behavior disorders in both chil-

dren and adults, criminals, especially those committing unreasoned

crimes of violence, alcoholics, and psychotic individuals. The presence

of a significant dysrhythmia in these groups has not been established. If

and when it is, electroencephalography both in diagnosis and in eugenics

will have a far-reaching career.

Clinical Data Bearing on Etiology. Although laboratory studies

must be the final authority for determining the ultimate etiology of

seizures, much can be learned from the study of patients. Several groups

of conditions have long been associated with the appearance of epilepsy.

946 PERSONALITY AND THE BEHAVIOR DISORDERS [31

HEREDITY. The subject of heredity has already been mentioned.

Statistical studies have shown that epilepsy occurs among the near

relatives of epileptic patients about five times more frequently than it

occurs in the general population (Lennox, 1941). This incidence is

greater if seizures began early in life, if the person shows mental deteri-

oration, if the patient is a female, and if the brain was not injured prior

to onset of seizures, so-called essential epilepsy.

Less than one-fifth of patients have a family history of epilepsy.

Hence seizures are not inherited, but only the tendency to seizures, a

predisposition which can be visualized as an hereditary dysrhythmia.

Presumably this dysrhythmia is present in all patients who are subject

to seizures, but it does not need to be so pronounced in patients who

also have received an injury to the brain. This conception is supported

by statistical evidence, which shows that persons having epilepsy subse-

quent to a brain injury have only half as many relatives with epilepsy

as patients who have had no injury. Incidence in the injured group is

still two or three times greater than in the general population. For prac-

tical purposes, epileptics are often divided into groups of so-called essen-

tial, or idiopathic, and the so-called symptomatic, or traumatic. Much

confusion has been created by this classification. In my opinion idio-

pathic is synonymous with hereditary. I believe nearly all cases are of

hereditary origin, but the importance of the hereditary factor varies,

being much smaller in certain patients than in others. Epilepsy may be

genetic or acquired, but it is most often of mixed origin.

STRUCTURAL ABNORMALITIES OF BRAIN AND BODY. Given a pre-

disposition to seizures, almost any abnormality of the brain seems to be

a precipitating factor. Changes which occur early in life in association

with intra-uterine or birth injuries, asphyxia, excessive sedation, and

so forth, seem to be particularly significant because the brain in early

life is unusually poorly protected and unusually sensitive to injury.

However, infections later in life, especially those involving the brain or

its coverings, trauma, tumors, and in later years degenerative change

in blood vessels of the brain, provoke seizures in predisposed persons.

Some injuries are much more important than others. Thus, gunshot

wound of the head is followed by seizures in from 5% to 20% of cases,

whereas tumors of certain areas of the brain are accompanied by seiz-

ures in the majority of cases.

The brain may suffer injury not only directly but as a result of

irritative substances carried to the brain from other parts of the body.

Thus disorders of metabolism which produce very low levels of sugar

in the blood result in convulsions, as does inadequate activity of the para-

thyroid glands, which results in an insufficient concentration of calcium.

EMOTIONAL COMPONENTS. As a gun may be fired by a very slight

pressure on the trigger, convulsions may be set off by emotional dis-

turbances which would produce only a storm of tears in an ordinary

individual. Some persons who are strong believers in the force of emo-

3 i] SEIZURE STATES 947

tional conflicts, especially those of the Freudian persuasion, attribute

convulsions wholly to unconscious conflicts. The point might be argued

at length. Perhaps the most significant piece of evidence is the lack of

reports of successful treatment of epileptic seizures by means of psycho-

analytical methods.

Differential Diagnosis Between Epilepsy and Borderline Con-

ditions. Patients and doctors are often put to it to distinguish between

symptoms due to epilepsy and those due to other conditions, principally

hysteria, syncope, and carotid sinus reflex. This problem is less acute

since the electroencephalogram has come into use. If records can be

obtained during a person's paroxysm and the record is normal, a cate-

gorical statement can be made that this is not epilepsy. If the record

is abnormal, the patient may possibly be one of those normal individuals

with an abnormal record or the dysrhythmia may be due to an injury

of the brain. However, when dysrhythmia and seizures are present in

the same individual, they are probably causally related.

HYSTERIA. A person having a hysterical seizure does not show more

abnormality of brain waves than he had before, and his convulsion can

usually be distinguished from that of the epileptic convulsion. How-

ever, the borderline is a broad one and physicians commonly make the

mistake of calling epilepsy hysteria. A history of emotional conflicts

can usually be elicited from a person who has hysteria. Seizures occur

in the presence of others ; the patient has something to gain by his attack,

and feels better for the experience after it is over. A person may have

both epilepsy and hysteria.

SYNCOPE. Fainting is due to an insufficient supply of blood to the

brain. The person becomes pale, falls limply, does not have convulsive

movements, and comes to in a few minutes. Syncope takes place when

the patient is upright, and does not occur when lying in bed. Recurrent

fainting episodes, especially if causative factors seem inadequate, need

to be looked on with suspicion.

CAROTID SINUS REFLEX. Rarely an individual, especially one who

is elderly with hardened arteries, will faint without apparent cause. If

the sinus reflex is at fault, fainting can be induced by pressure on the

carotid sinus, which lies at the bifurcation of the carotid artery in the

neck.

Means of Altering the Frequency of Seizures.

PHYSICO-CHEMICAL CHANGES. Induction of acidosis tends to in-

hibit seizures, particularly those of the petit mal type. Acidosis can be

induced by fasting, by the use of a ketogenic diet, by the ingestion of

acids or acid forming salts, by breathing high concentrations of carbon

dioxide, and most easily of all by strenuous muscular exercise or work.

The opposite condition of alkalosis induced by overventilation or in-

gestion of large amounts of bicarbonate tends to increase seizures.

948 PERSONALITY AND THE BEHAVIOR DISORDERS [31

Dehydration of body tissues through abstinence in the use of fluids tends

to reduce seizures, and flooding the body with water tends to increase

them. In the laboratory, petit mal seizures can be decreased by breath-

ing high concentrations of oxygen and can be increased by reducing the

oxygen content of the blood. Alteration of chemical constituents of the

blood, particularly sugar, calcium, and possibly cholesterol, also modi-

fies seizures.

DRUGS. Convulsive drugs will produce seizures more readily in

epileptic patients than in others. Curiously enough, some clinicians have

induced convulsions in patients with the hope of thereby "discharging"

the brain and preventing the occurrence of spontaneous seizures. Re-

ports are not in agreement as to whether the induced attacks are the

same pattern as spontaneous ones. Drugs are of course used principally

to prevent seizures, a subject which will be discussed under treatment.

PROPHYLAXIS. Efforts to prevent seizures may be either communal

or individual. Public efforts consist of the prevention of birth injuries

and of head injuries, and the reduction of infectious diseases which play

a part in precipitating attacks. More important than these would be the

limitation of offspring of persons who are either subject to seizures or

have pronounced congenital cerebral dysrhythmia.

Individual prophylaxis consists in the avoidance of head injuries or

of infections which attack the brain and in extra care given to persons

who may be predisposed, presumably those individuals who show corti-

cal dysrhythmia. The efficacy of drugs in the correction of asympto-

matic dysrhythmia has not yet been demonstrated. Certain symptoms

such as unexplained night terrors, fainting, attacks of sleep, or outbursts

of temper may be premonitory or disguised symptoms of epilepsy, and

presumably if treatment is started early, frank seizures might be avoided.

Treatment.

PHYSICAL. Most patients think only of the necessity of being rid of

the seizures. But in many a patient the elimination of seizures is but

half the battle. With this accomplished, he may be so fearful of their

return or so out of gear with his environment that he requires psycho-

logical care.

Treatment must be individual, for the causes of seizures vary in

different individuals. The first and most important consideration is the

elimination of the responsible factors. The fundamental, hereditary,

cause cannot of course be treated, but numerous contributing causes can

be. If there is evidence of a focal cortical lesion, surgery may be required

for removal of the scar or of the tumor which is responsible. Abnor-

malities of physique need to be corrected even though they may play a

very small part. Very rarely a glandular disorder or a state of allergy

can be remedied with benefit. Aside from individual abnormalities

which possibly are directly responsible for seizures, many patients can

be helped indirectly through improvement of habits of living and of gen-

3i ] SEIZURE STATES 949

eral physique. Specifically, the induction of a state of acidosis by means

of the ketogenic diet has relieved about a third of children who have been

given this treatment. Institution of dehydration by means of extreme

limitation of fluid intake has been found helpful by some doctors.

Therapeutic results are difficult to evaluate, because of the natural tend-

ency to remissions, sometimes of considerable duration, without apparent

cause.

PHARMACOLOGICAL. In 1857 Sir Charles Locock reported good re-

sults from the use of bromide; in 1912 Hauptmann first reported the

use of phenobarbital ; and in 1937 Putnam and Merritt gave the favor-

able results of experiments with dilantin sodium (sodium diphenyl

hydantoinate). Each of these drugs has proved to be more valuable

than its predecessor. At the present time, phenobarbital is used most.

The daily dose is from one to two grains, but as much as six grains a

day may be used in some patients without apparent harm and without

producing the disfiguring skin lesions or the drowsiness caused by

heavy dosage of bromide. Dilantin is probably the drug of choice,

although many patients are not benefited or suffer toxic symptoms. In

any case the administration of dilantin requires much more careful super-

vision than the other two drugs. The beginning dose for adults is one

and a half grains three times a day. If toxic symptoms do not appear

and if attacks are not controlled, the amount may be increased gradually

by steps until therapeutic results are obtained or until a maximum of

nine grains a day are taken. The most frequent toxic symptoms are

instability of gait, tremor, gastric upsets, eruptions of the skin, swelling

of the gums, or, in rare instances, overactivity and psychic disturbance.

The appearance of any of these symptoms necessitates reduction of the

dose or, if they are alarming, its discontinuance. All three of these

drugs are most effective with grand mal attacks. Petit mal attacks are

little influenced ; in the case of dilantin they are often made worse. On

the other hand, dilantin is particularly effective in cases of psychomotor

seizures, which are not usually helped by the other two. Dilantin has a

great advantage over the other two in that it is not a hypnotic and there-

fore its use does not result in a slowing of mental activity.

Public Responsibility. The public has assumed direct responsi-

bility for the care and treatment of that considerable group of patients

who cannot readily be cared for at home. For the most part these are the

patients who are seriously deteriorated or whose behavior is a trouble

or menace to others. In most states of the Union these patients are sent

to a mental hospital. This disposition is especially unfortunate if the

person's mentality is not impaired. Even if it is, patients subject to seiz-

ures require different handling from those who are psychotic. Recog-

nizing the peculiar needs of the epileptic patients, ten states have estab-

lished hospitals or colonies which are exclusively for the care of epileptic

patients. Altogether, these hospitals contain some 13,000 patients, out

of the 50,000 or so who are in public charge. There are only two or

95 o PERSONALITY AND THE BEHAVIOR DISORDERS [31

three small private institutions designed for epileptic patients. The

problem of care for an epileptic outside of the home and outside of a

state institution at a moderate cost is not adequately met.

Education of the Public. The public stands in need of education

concerning both the medical and the social aspects of epilepsy. Many

opinions are widespread which stem from a century ago. Especially is

this true with regard to questions about heredity and mental deteriora-

tion. Books designed especially to correct this condition are Science and

Seizures (Lennox, 1941) and Convulsive Disorders (Putnam, 1943).

The only organization is the Laymen's League against Epilepsy. Mem-

bers receive educational bulletins and are expected to spread authori-

tative information and through their dues to contribute towards research.

A Program for Investigation. The fruitfulness of work done in

the last five years with electroencephalography and with dilantin

demonstrates what can be done by intensive effort. Further research

should be productive of even greater results because the main problems

of epilepsy are now laid bare. They are physico-chemical in nature.

Because the abnormal discharges can be recorded, the conditions and

chemicals which influence these discharges can be studied. This work

of course requires expert investigators and expenditure of considerable

amounts of money. Many obscure points can be cleared up by clinicians

who are in contact with patients and who really are interested in con-

tributing to knowledge. The American League against Epilepsy is a

branch of an international organization whose members are, many of

them, engaged in research.

Migraine

This symptom complex resembles epilepsy in the fact of recurrence.

Like an epileptic seizure, an attack may come only once in a lifetime

or may occur several times a week or even become almost continuous.

History. Aretaeus, who lived in the second century A.D., describes

recurrent headaches which are unmistakably migrainous. Writers in the

middle ages make frequent reference to it. A long case history which is

startlingly clear is by Thomas Willis, whose first complete works were

published in 1684.

Incidence. No exact statistics are available. Samples from small

groups vary tremendously with the age, sex, and social condition of the

groups tested. About two-thirds of patients who consult physicians are

women. A moderate estimate based on samples of the population is

5%.

Relationship to Epilepsy. Aside from the fact of recurrence,

epilepsy and migraine seem to be genetically related in that the inci-

dence of epilepsy and migraine in the same person is greater than the

incidence of either in the general population. More significant is the

3 i ] SEIZURE STATES 951

fact that the incidence of migraine is unduly high among the relatives

of epileptic patients and an unusual number of relatives of migraine

patients have epilepsy (Lennox, 1941).

Symptomatology. The symptom of greatest importance to the

patient is a pain in the head which is usually so severe as to be incapaci-

tating. It is usually localized and characteristically is confined to one

side of the head, hence the old term "hemicrania." The pain, however,

has a tendency to wander during an attack and to be present in different

parts of the head with different headaches. Nausea, usually accom-

panied by vomiting, and sympathetic disturbances, pallor, chilliness,

gooseflesh, changes in pulse rate, are usually present. Some patients

experience visual symptoms, blind spots, a blurring of vision or zigzag

colors. Headaches are relieved with difficulty by ordinary sedative

drugs, but in the great majority of cases are relieved promptly by the

nonsedative ergotamine tartrate.

Mechanism of Seizures. The symptoms which have been named

indicate a primary disturbance in the autonomic nervous system. The

site of pain is probably in the arteries which supply the meninges and

is due to an undue relaxation of arterial walls. The nausea, and vomit-

ing, and the scotoma or, when they occur, the hemiparasthesias or hemi-

paresis, presumably indicate disturbance of cortical cells, which may be

due to alteration of vascular supply.

Etiological Factors. Heredity is outstanding and a positive history

of affected relatives is obtained in three-fourths or more of patients who

have the characteristic symptoms. The mothers are of course more

often affected than fathers.

Endocrine influences are more prominent than in the case of epilepsy.

This is especially observable in women. Headaches are prone first to

manifest themselves at the time of puberty and in association with

menstruation. Many women are free of attacks during pregnancy and

seizures tend to disappear with menopause.

Emotional factors are also more prominent than with epilepsy. The

majority of patients relate attacks to periods of emotional stress.

Prophylaxis. Obviously the most important point is choice of parents

who have no personal or family history of migraine or epilepsy. In a

person who is predisposed the manifestation of seizures might possibly

be minimized or averted by avoidance of conditions such as emotional or

physical fatigue, eye strain, or undue sensory stimuli which seem to

precipitate attacks.

Treatment. As with epilepsy, treatment is individual, based on what-

ever abnormalities can be uncovered as a result of careful examination.

The body must be brought into as perfect a state of health as possible

and the method of living regulated to avoid undue stresses, internal as

well as external.

952 PERSONALITY AND THE BEHAVIOR DISORDERS [31

PHARMACOLOGY. Ergotamine tartrate, given by subcutaneous in-

jection in .5 mg. doses, is effective in aborting individual attacks of head-

ache in about 90% of persons so treated. It stops not only the headache

but also the other symptoms, although nausea and vomiting are at first

accentuated. Apparently the pain from sensory stimulation by relaxed

arteries is overcome by an increased tonicity of the arterial system. Pre-

sumably the fact that arteries of the head are alone involved is due to the

autonomic nervous system supply and control of these arteries. Very

rarely a patient will be encountered whose pain is not in the head but in

the abdomen.

Program for Investigation. More needs to be known about the

chemical influence of hormones, the relationship of emotional disturb-

ances to the action of the sympathetic nervous system, and a much larger

collection needs to be made of statistical data.

Personality and Seizure States

This is an interesting subject which has received too little unbiased

attention. Neither Gowers (1901) nor Liveing (1873) in their exhaus-

tive books on epilepsy and on migraine mention the subject. In epilepsy

the problem of personality and behavior is intertwined with that of men-

tality. In migraine this difficulty does not arise.

Mentality in Epilepsy. We must first clarify the subject of mental

impairment in epilepsy. Emphatically, poor mentality is not necessarily

a feature of epilepsy. Of 1,640 clinic and private patients who had "essen-

tial" epilepsy, 67% were classed as mentally normal, 23% as slightly sub-

normal, 9% as definitely deteriorated and \% as markedly deteriorated

(Lennox, 1941). Thus only one patient in ten would be immediately

recognized as subnormal. Of course the proportion is necessarily higher

in institutional patients, for the patient's defective mentality is a prime

reason for taking the patient from the home. Of patients entering New

York's Craig Colony only 11% are mentally normal.

Defective mentality when it occurs may be blamed on one (or more)

of five causes :

CONSTITUTION HEREDITARY. Congenital physical defects are more

common among deteriorated than among mentally normal epileptics

(Paskind and Brown, 1936). Patients who are mentally defective at

birth have twice as many relatives with epilepsy, and four times as many

relatives with psychosis as epileptic patients who are normal at birth

(Lennox, 1941).

INJURY TO THE BRAIN BEFORE THE ONSET OF EPILEPSY. Such an

injury may be a principal cause of both seizures and mental defect. Of

patients who had a preexisting brain injury 54% were mentally normal,

against 67% who had no brain injury.

3 i ] SEIZURE STATES 953

DEFECTIVE MENTALITY A RESULT OF SEIZURES. Factors which play

a role are the duration of the disease, the type of seizures and their num-

ber, and the type and frequency of brain dysrhythmias. The passage of

time is especially influential in the first fifteen years of the disorder. In

the group studied by Lennox (1941) 24% were found to be abnormal

during the first years of the disorder and 54% abnormal if the disease

had persisted more than 25 years. There is progressive decrease in men-

tality with the total number of attacks, especially if these are psycho-

motor or grand mal, or a combination of these. Cases with pure petit mal

may go unscathed. Also the three-a-second wave and spike dysrhythmia

of petit mal epilepsy when it occurs without clinical manifestations seems

innocuous. Chronic epileptics who are seriously deteriorated very often

show abnormally slow waves on the electroencephalogram. Presumably

this slowness accompanies the downward progress of the disease. Feeble-

minded persons without a history of seizures do not have this slowness.

Whether this type of dysrhythmia is prognostically significant in incipient

epilepsy has not been determined.

Again, intermittent mental sluggishness may be but the expression of

continuous stretches of dysrhythmia. A condition of petit mal status may

produce a foggy mental state which clears when the brain waves become

composed (Putnam and Merritt, 1941).

THE EFFECT OF DRUG THERAPY. The sedative drugs, bromides, and

phenobarbital, if given in large enough quantities may either induce a

state of mental sluggishness or in certain patients may induce psychotic

states.

PSYCHOLOGICAL STATES SIMULATING DETERIORATION. Apparent

mental sluggishness may be only profound discouragement and self-

centered interest brought on by psychological and social mistreatment.

More than one of these factors may be at work in a given individual.

The last two are susceptible to direct treatment and improvement.

More certain light is shed on this question by mental testing of groups

of patients, especially if continued over a period of years. This has been

done for small groups of clinic patients by Wallin (1923), Fox (1924),

Branham (1925), Patterson and Fonner (1928), Dawson and Conn

(1929), Abadie (1932), Doolittle (1932), Wooster-Drought (1934),

Bridge (1934), Fetterman and Barnes (1934), Sullivan and Gahagan

(1935), Collins, Atwell, and Moore (1938), Kugelmass, Poull, and

Rudnick (1938), Somerfeld-Ziskind and Ziskind (1940), and Collins

(1941). Unfortunately the results are distorted by the fact that not all

the original patients are followed throughout the period. Some of these

authors also studied the defects of mentality which were most consistently

displayed by their patients. Memory is the principal loser.

Personality Disorders in Epilepsy. Cowers (1901) may have

failed to mention personality changes in epilepsy because he dealt with

clinic and private patients. Spratling (1904), superintendent of Craig

954 PERSONALITY AND THE BEHAVIOR DISORDERS [31

Colony, spoke of mental peculiarities, emotional instability, impulsive-

ness, moral anergia, and incapacity for productive occupation involving

initiative and consecutive activity. In about three-fourths of patients an

approaching convulsion was heralded by querulousness, fault finding,

and the dominance of trifles.

In this country L. Pierce Clark was the most prolific advocate of the

epileptic personality, his articles appearing between 1914 ana 1933. His

principal contact was with patients in Craig Colony at Sonyea, New

York, where for years he was a member of the staff.

Clark states that Kraepelin, Turner, Bianchi, and Vogt had recognized

a peculiar personality in epileptics. The characteristics which Clark prin-

cipally emphasizes are four: eccentricity, supersensitiveness, emotional

poverty, and rigidity. Contrary to general opinion, these characteristics,

says Clark, are not the result of continued seizures, but are encountered

in the history obtained of the patients before seizures began. They be-

come accentuated, however, during the progress of the disease. He esti-

mates that 60% to 70% of all persons subject to seizures have the de-

scribed personality. These patients he defines as essential, and others as

symptomatic epileptics. He admits that some normal persons may have

the same characteristics in an attenuated form. Clark (1918a) secured

information about 50 private patients by means of a blank containing 121

questions, an amended Hoch-Amsden guide to personality. He found

that only two or three had been normal as babies. The majority had evi-

dence of frequent irritability, excessive crying, peevishness, excitability,

lability of mood, short-lived interest, tantrums, hypersensitivity, and in-

sistence on having their own way. During the period of school age,

three-fifths of the patients were average in their studies, although there

were fluctuations in mood and interest, and two-fifths had difficulty in

keeping pace. They were inattentive, restless, irritable, and unable to

follow school routine. Their voices were harsh and unmelodic, without

the normal up and down rhythm. Children were inclined to be turbulent,

argumentative, quarrelsome, had no sense of inferiority, and little imagi-

nation. Movements were slow, clumsy, and oftentimes grossly incoordi-

nate. Children resented correction, were stubborn and selfish. Many

showed abnormal personal attachment to the mother, were conceited,

egotistical, their clothes and personal possessions must be just so. Al-

though lenient with themselves, they were punctilious in their demands

on others, looked down on servants, and demanded a keen sense of honor

in others. Inclined to excuse their own faults, they had no forgiveness

for the failings of others. Unlike the psychoneurotic, who is preoccupied

with his own body, the epileptic is more solicitous about his ego.

In social relationships, said Clark, the person predisposed to epilepsy

has no intimate friends and makes no effort to be popular. He is soli-

tary, except with persons either older or younger than himself. Unlike

the feebleminded, he is not gregarious. He has little tact, and gets his

own way by persistence or by a fixed attitude of noncooperation. Be-

cause he resents correction, the family is inclined to adopt a let-alone

31] SEIZURE STATES 955

attitude toward him. He demands precision and order, is committed to

routine, is easily hurt, carries grudges, is resentful, jealous, envious, and

resents discipline and exact rules laid down for his conduct. A first

attack is sometimes precipitated because of the stress caused by rigid

demands made upon him. He is sensitive because he has no rich emo-

tional feelings to impart. In this respect also he is unlike the psycho-

neurotic, who is daydreaming of his own aggrandizement. He has

periods of depression, is stoical in bereavement, in religion superficial,

pietistic, perfunctory. Dr. Clark gives examples of these religious char-

acteristics in the founders of Shakerism, of Mormonism, and of Moham-

medanism. In the adult, emotional life is not developed beyond that of

puberty. Sexual life is perfunctory. An epileptic has no deep love motive.

He is ill at ease with the opposite sex and has no desire for children.

He is not ordinarily antisocial or criminal, nor is he cruel to animals.

He has no tenacity of purpose, although his verbal ambitions are bound-

less. Work is poorly performed, without precision. To keep him at

work requires constant change of occupation, emotional enthusiasm, and

praise.

Every case of essential epilepsy, says Clark, shows some of these traits

to a marked degree. This observation rather begs the question because

Clark diagnosed essential epilepsy only if specific personality traits were

present.

As for the observations of other authors, Notkin (1928) observed the

epileptic "make-up" in 17% of 150 nondeteriorated clinic patients, these

being cases whose epilepsy began before the age of twelve. He believed

the "make-up" was the result of seizures and not their cause. The per-

sonality was pure schizoid in 8% of cases, and became schizoid in the

course of the disease in another 8%. Personality disorders were variable

rather than specific. Dawson and Conn (1929) blamed personality dis-

orders on the lowered mental state of their patients, which causes a dis-

integration of control over the lower, more instinctive reactions. Eyrich

(1932) stressed three elements: first, retarded mental processes (apper-

ception, thought, activity, reaction time, a "general vacuity") ; second,

explosive excitability ; and third, motor restlessness without a goal. Doo-

little (1932) noted the progressive nature of the disorder in institutional

patients. Sullivan and Gahagan (1935) made mental tests and listed

personality or conduct disorders in 103 children referred to a psycho-

logical clinic. Fourteen were feebleminded. Intelligence quotients ranged

from 11 to 141. The median was 92, against 105 for a large group of

school children and 103 for a small group of allergic patients. Among

the epileptics, approximately one-half had serious personality difficulties

or conduct disorders. The mean IQ of problem cases was 75 and of

nonproblem cases 88. Early onset of seizures was associated both with a

lowered IQ and an increased proportion with personality disorders. Like

delinquency in nonepileptic children, such disturbances were greater

when the home environment was poor. The disorders of these children

were divided almost equally between hyperkinetic behavior (overactivity,

956 PERSONALITY AND THE BEHAVIOR DISORDERS [31

fidgety, "constantly into things," ill at ease), emotional disturbances

(temper tantrums, cruelty to children and animals, fighting, destructive,

high strung, mischievous, teasing, truancy, negativistic, rebellious, moody,

stubborn, self -centered), and conduct disorders (bad sex habits, lying,

stealing, disobedient, naughty).

Diethelm (1934) found personality features ordinarily associated with

epilepsy among relatives of epileptic patients indicating that such features

are a constitutional characteristic, but believes that the issue is not the

presence of disorders but their evaluation in the whole personality set-

ting. In a study of 54 patients with "essential" epilepsy, Fleck (1934)

listed the following characteristics : moroseness, indifference, circumstan-

tial and stereotyped manner of speaking, and limited content of speech,

egocentricity, irascibility, hypersociability, and religious devotion. He

attributes many of these symptoms to brain injury, since they appear

also in nonepileptic persons with brain pathology. In their study of the

cortical electrical records of behavior problem children, Strauss, Rahm,

and Barrera (1940) used three categories: (1) assaultive, destructive,

disobedient, with constant irritability and hostility to their environment ;

(2) runaway type with fugue-like states; (3) episodic temper outbursts

with relatively normal type of behavior between outbursts.

Significance and Causes. These various contributors to the subject

have given a long list of attributes, all of them undesirable from the point

of view of society and of the patient himself. In justice, it should be

pointed out that many epileptics have very agreeable personalities and a

considerable number occupy permanent positions of fame. In my experi-

ence, the majority of persons subject to seizures who are encountered in

office and clinic do not exhibit the undesirable traits which have been

named. Obviously much depends on the bias of the reporter. No "con-

trol" observations have been conducted with the aim of ascertaining

whether, for example, egocentricity, emotional poverty, or rigidity is

more common in a group of epileptics than in a group of artists, of psy-

chologists, or of doctors. Granted that the described traits are unusually

common in epileptics the question arises as to their significance. A

number- of possibilities exist.

1. The traits may be nonspecific. Certainly egocentricity, irritability,

moroseness, and so forth occur in the victims of many other chronic and

disabling diseases, such as heart disease, arthritis, and alcoholism.

2. The personality traits may be constitutional and the direct cause of

seizures. This is the thesis of Clark, Stekel, and others and deserves

examination. If the traits are constitutional and hereditary, then they

will be found in many of the nonepileptic relatives of the patient. Clark

declares this is true. Though he depicts only one family tree (1916), he

states that Kraepelin found the epileptic traits in 87% of the families of

epileptics (Clark, 1931). If peculiar traits are diagnostic of epilepsy, or

if they are regularly present before seizures appear, or are constantly

present in the family trees of epileptics, then they might be considered

3i ] SEIZURE STATES 957

a constitutional characteristic of essential epilepsy similar to distorted

anthropomorphic measurements.

Clark believed that the seizures of epilepsy are psychological in origin.

The adult epileptic is only prolonging the fantasies of youth. His attacks

represent efforts to regain the intra-uterine state, or they represent re-

action to unconscious repressed desires. The epileptic's emotional life is

defective because of mental infantilism. The essential nucleus of this

defect is a too intense and prolonged fixation of the libido. His ego-

centric tendencies are due to the self-centered strength of his sexual

energies. The seventy of the fit is in direct proportion to the outlet

demands of the unconscious libido. Clark and Gushing (1931) say the

epileptic attack is a return to the Nirvana of the womb. In the epileptic,

( 1 ) the death instinct may be stronger, the exaggerated pull of it result-

ing in the attack ; (2) he may need more libido to be fused with the death

instinct in order to bring about the destructive (sadistic) force of mas-

tery which would take the person further into reality; (3) in the fusion

between libido and death instinct, the proportion of self-destructive forces

is stronger; the desire then to be humbled may be greater (masochism)

and may show in the annihilation of the ego, represented by the attack.

Because the epileptic fit is accompanied by unconsciousness, MacRobert

(1916) says the patient's nonconscious mentality is saying, "I wish I

had never been born, and could return to a state of prenatal uncon-

sciousness/' He further believed that dreams could precipitate seizures.

Gottke (1934) in a 45-page article on the subject of dreams found little

evidence of this. Seizures could not be induced by hypnotic suggestion.

Unlike narcolepsy, the periods of the seizures and the subsequent sleep

are dreamless. Deteriorated patients apparently dream little; Jelliffe

(1935) agrees that the epileptic personality is a manifestation of sadistic

and aggressive drives, while the fit itself represents the triumph of the

death instinct, destroying itself and the future. Both the paroxysms of

whooping cough and the epileptic fit are symbolic reactions to an agency

which has threatened the life instinct. Cronin (1933) psychoanalyzed a

pair of identical twins, one of whom had a convulsion as a result of an

emotional impasse. Symbolically he had been castrated and had sadisti-

cally attacked his castrators but failed. Stekel, quoted by Karpman

(1934), says the epileptic is distrustful, egotistic, sly, a strong hater, and

liable to transfer this hatred to the analyst. The hate is carried into

action in the uninhibited, and to a convulsion in the inhibited.

3. A peculiar personality and a tendency to seizures may be hereditary

traits which are linked together but not causally connected. An undue

proportion of parents and siblings of the patient should show similar

personality traits, but like the bizarre anthropomorphic measurements

described by Paskind and Brown (1939) the traits are concomitants and

not causes of seizures. If seizures and personality are linked genetically,

peculiar personalities should be more prominent among the relatives of

epileptic patients who belong to those groups in which heredity is more

pronounced, the "essential" patients, the females, those whose seizures

95 8 PERSONALITY AND THE BEHAVIOR DISORDERS [31

began early in life, and those who are mentally deteriorated. If per-

sonality and the predisposition to seizures are linked genetically, and if,

as I believe, a predisposition to seizures is accompanied by cerebral

dysrhythmia, then those relatives of patients who have cortical dysrhyth-

mia should also have a peculiar personality. This possibility is suggested

also by the fact that a large proportion of children with behavior dis-

orders exhibit cortical dysrhythmia. However, our experience with 150

relatives of epileptics who have abnormal brain waves indicates that

dysrhythmia is not usually accompanied by an epileptic personality.

An excellent means of separating hereditary from other influences is

the study of identical twins, only one of whom has epilepsy. Freeman

(1935) reported such a case. I have seen seven such pairs. The non-

epileptic twin always had dysrhythmia, but peculiarities of personality, if

present, were more pronounced in the affected twin, an indication that

factors other than heredity were mainly responsible.

4. Personality disorders in the epileptic may be simply a special kind

of seizure. When bad behavior and grand or petit mal seizures occur in

the same patient, the possibility is patent. Yet even without the presence

of classical seizures, the abnormal behavior may be suspicious. Maudsley

(1870) expressed the matter clearly: "Children of three or four are

sometimes seized with attacks of violent shrieking, desperate stubborn-

ness or furious rage, when they bite, kick and do all the destruction they

can ; these seizures, which are a sort of vicarious epilepsy, come on peri-

odically, and either may pass in the course of a few months into regular

epilepsy, or may alternate with it." This is as true for adults as for chil-

dren. Maudsley quotes Mo/el in saying that epileptic neuroses may exist

in an undeveloped or masked form showing itself not by convulsions, but

by periodic attacks of mania or by manifestations of moral perversion

deemed wilful viciousness. But, says Morel, no moral influence can touch

them for they depend on a morbid physical condition which can only

have a physical cure. They get their explanation afterwards when

epilepsy occurs. Maudsley speaks of a "convulsive idea" which is strictly

comparable with an epileptic convulsion. A murderer butchered a child,

wrote in his diary "Killed a little girl ; it was fine and hot," and when

questioned could give no reason for his crime. Says Maudsley, "When-

ever a murder has been committed suddenly, without premeditation, with-

out malice, without motive, openly, and in a way quite different from

the way in which murders are commonly done, we ought to look care-

fully for evidence of previous epilepsy, and other symptoms allied to

epilepsy." The Flemish painter Van Gogh had similar periods, except

that the violence was inflicted upon himself. He cut off one of his ears,

and finally shot himself in the abdomen.

Other episodic incidents may also be classed as epileptic. Brickner

and Rosner (1939) described a patient with five- or six-second periods

of alternate depression and elation without loss of consciousness. Davi-

doff's (1939) patient, after a head injury, had paroxysmal, uncontrollable

ideas and cerebral dysrhythmia. In our laboratory we have found heredi-

3i ] SEIZURE STATES 959

tary cerebral dysrhythmia in a number of patients whose psychomotor

seizures were only peculiar or abnormal behavior. As Lindsley points

out in another section, a considerable proportion of behavior problem

children have cortical dysrhythmia.

An investigation of obvious importance, social as well as scientific,

will be the electroencephalographic examination of a sample of our prison

population, men and women who are incarcerated because of deeds of

violence. If a considerable proportion of these have cortical dysrhythmia,

this fact would give backing to Maudsley's contention that their treat-

ment should be physical rather than moral. The legal aspects of epileptic

amnesia are discussed elsewhere (Lennox, 1943).

A convulsion, a nasty word, and/or a habit of perseveration may each

be an expression of cortical dysrhythmia. This possibility is a demon-

strable fact in the case of certain patients and certain reactions. A psy-

chomotor seizure may be an acute period of bad behavior accompanied

by a prolonged sequence of slow high voltage cortical waves. Again on a

day when a patient is negativistic or surly, his brain wave record will

be more abnormal than on a day when he is sweet-tempered. In such

instances the abnormal personality is not the result nor the accompani-

ment of epilepsy, nor an epileptic equivalent : it is epilepsy. The case

for the significance of coincidentally fluctuating abnormality in brain

waves and behavior seems proven. High barometer, fine weather ; low

barometer, stormy weather.

Not so evident is the case of the person who has an abnormal electri-

cal record and traits of personality which are constantly present, such

as a limited range of ideas and of interests. Abnormal records are not

confined to persons who have clinical symptoms. Perhaps 15% of

"normal" persons have dysrhythmia. To demonstrate a relationship of

brain rhythms to behavior, determination should be made of the inci-

dence of dysrhythmia in groups of persons who show, and do not show,

disorders of personality. We have the material for such a study in the

electrical records of the nonepileptic relatives of epileptic patients. A

little more than one-half of these relatives have cortical dysrhythmia.

If one of two parents has abnormality of rhythm, he is more likely to be

the one who is "flighty," excessively apprehensive, uncooperative, or

inflexible. However, some of the most normal of relatives have the worst-

looking tracings. In fact it is entirely possible that unusual waves, too

glibly called abnormal, may be associated with unusual brilliance or with

supernormal personality. As Lombroso pointed out, genius and eccen-

tricity, epilepsy and high achievement may reside in the same individual.

Gross dysrhythmia is consistent with normal personality. Pursuit of the

subject may require a more explicit technique for studying both person-

ality and brain waves. Gallagher and Gibbs (1942) have placed the

results of electrically analyzed records of brain waves against the evalu-

ation of the personality and performance of adolescent boy students.

Boys with poor personality tend to have slow waves, and those with good

personality fast waves. This promising field is ripe for the harvest.

960 PERSONALITY AND THE BEHAVIOR DISORDERS [31

5. Brain pathology may be responsible for both epilepsy and bad

behavior, or repeated seizures may cause brain damage and this in turn

cause changes in character. The behavior would then be secondary or

even tertiary. Personality changes after brain trauma and encephalitis

are dealt with in the chapter by Cobb. Study of the effect on personality

of the severe convulsions of "shock therapy" for schizophrenia should

help in the evaluation of this factor. Study of identical twins only one

of whom has brain damage and epilepsy has been mentioned.

6. Personality changes may result from the altered social environ-

ment in which the epileptic finds himself. This environment may be

oversoft and yielding, making for bad behavior and selfishness, or more

often, openly cruel and hostile. Persons with chronic incapacitating

diseases of all sorts, cardiac or joint cripples, the blind and hard of hear-

ing, tend to become suspicious, querulous, and self-centered. Even a

normal person if shut out of schools and employment and shunned by

companions would in time develop unpleasant traits. In order to evaluate

the influence of both physical and psychological injury, more information

is needed about the degree of abnormality present in the period before

seizures began in comparison with afterwards. Also the influence of the

type of seizure is important. In my experience, patients who have only

petit mal, a seizure which carries little stigma and does no brain injury,

display relatively little evidence of the epileptic personality.

7. Overdosage with sedative drugs may cause temporary periods of

surliness or even psychosis. In fact many of the features of the "epileptic

personality" could be reproduced by feeding excessive amounts of bro-

mide or phenobarbital over prolonged periods. This possibility has re-

ceived little attention in the studies of Clark and others which have been

mentioned. The decreased emphasis on the epileptic personality in recent

years may be due to the fading popularity of bromides. Only a rare

neurologist like Pollock (1938) sticks to this 85-year-old drug.

8. The personality disorders may not be a result of the epilepsy nor

yet a distinct quality or characteristic of patients, but an expression of

mental retardation. In Sullivan's series, problem children constituted

36% of those with an IQ above 70 and 74% of those with an IQ below

70. Defects of mentality and of personality often overlap.

In a given patient, more than one of these eight causes might be oper-

ative, or some might be responsible in patient A and others in patient B.

Also, of the various traits mentioned, some might be due to one cause

and some to another cause. For example, rigidity might be due to

heredity, perseveration to impaired mentality, negativism to subclinical

dysrhythmia, moroseness to drug therapy, and egocentricity to social

ostracism.

The Rorschach Test. As mentioned on a previous page, a difficulty

in studying personality in epileptics has been the lack of objective meas-

urements of traits which do not express themselves in conduct. One pos-

sible method is the ink-blot test devised by Rorschach. The purpose and

3 i] SEIZURE STATES 961

application of this test is described by White (Chapter 6). A number of

authors have described a peculiar type of response to the test given by

epileptics. The largest number of cases is found in the monograph by

Stauder (1939). He agrees with Rorschach that epileptics give a typical

response. The characteristics of epileptics which the test reveals in-

directly are disturbances of perception, of judgment and of memory;

thought which shows poverty of content, retardation, stickiness, circum-

stantiability, pedantry, and good-natured dullness ; and action which may

be explosive or denote irritability. The outstanding symptom of epilepsy

is perseveration.

These abnormalities of personality, says Stauder, are inherent in

epilepsy and are not the result of seizures, for they are as prominent in

patients with few as with many attacks. The relatives of epileptics may

show the characteristic Rorschach syndrome. The progressive person-

ality change of epilepsy is an indispensable symptom of hereditary

epilepsy. Genuine epileptics without signs of epileptic personality change

do not exist. Stauder therefore defines epilepsy as a tendency both to

seizures and to specific personality changes. Three conditions accentuate

the epileptic personality: an athletic constitution (found in 16% of 600

epileptics), the use of phenobarbital, and a certain type of seizure. Any

condition which disturbs normal consciousness is a determining factor in

the production of the Rorschach syndrome and the epileptic personality.

The Rorschach epileptic syndrome is present in normal persons who

had received large doses of phenobarbital. Epileptics whose Rorschach

test was normal would present the epileptic syndrome if given pheno-

barbital or if in a cloudy mental state following a seizure. Stauder be-

lieves that phenobarbital accentuates the abnormal personality and psy-

chopathology of patients. Seizures which involve prolonged clouding of

consciousness are the hardest on personality. Petit mat seizures do less

harm.

Mental deterioration, says Stauder, is distinct from these personality

disorders, and is not distinguishable from the dementia of other diseases.

Unlike personality disorders, the degree of dementia is related to the

number of seizures. Severe dementia blurs the typical epileptic Rorschach

syndrome.

Stauder reserves the term "genuine epilepsy" for patients with an in-

herited tendency to seizures and personality disorder. Of traumatic or

symptomatic epileptics, about four-fifths have some elements of the

Rorschach syndrome and are called "provoked" epileptics. About one-

fifth have abnormal Rorschach response and are termed "exogenous"

epileptics. Then there is a small group, 31 out of the hundreds tested,

who have few seizures and symptoms and would be called genuine except

that they are normal mentally and by Rorschach test. These, called func-

tional epileptics, have no relationship to genuine hereditary epilepsy.

Then there are the persons (relatives of patients) without seizures but

giving the Rorschach response, the epileptoids.

Though written in cumbersome, repetitious German manner this

962 PERSONALITY AND THE BEHAVIOR DISORDERS [31

monograph is a definite contribution to the psychological study of epi-

lepsy, and is a challenge to workers in this field. The issue is clear-cut

and can be easily decided. If the personality of the patient which shows

itself in a specific type of response is synonymous with hereditary epi-

lepsy, and if, as I believe, the hereditary predisposition to epilepsy can

be demonstrated by the electroencephalograph, those relatives of epilep-

tics who have abnormal brain waves should give the Rorschach response

associated with epilepsy and those with normal brain waves should not.

Harrower-Erickson (1941) finds no consistent Rorschach response in

patients of normal intelligence, and believes that brain injury or adverse

environment is chiefly to blame for whatever personality difficulties are

present. The fact that normal individuals give a typical Rorschach re-

sponse when under the dulling influence of sedative drugs is against the

specificity of the response. Also against the value of the Rorschach test

in judgment of hereditary traits are the observations of Troup (1938).

From a study of ten identical twins she concluded that cultural influ-

ences are a greater influence in Rorschach responses than hereditary

influences.

Summary. The divergent factors involved and views expressed

make it difficult to summarize the subject of personality in epilepsy. It

would seem that the subject of a specific epileptic personality has been

overemphasized, because most of the contributors to the subject have

dealt with institutional patients. In these patients both mental deteri-

oration and personality disorders predominate and are probably asso-

ciated. Thinking of the 90% of patients who are outside of institutions,

the following statements may be made:

1. The majority of such patients show no gross evidence of a peculiar

personality or of unusual behavior, at least no more than samples of the

general population.

2. Of the minority group who show peculiarities, these traits for the

most part are a result of the seizure state, either of the associated pa-

thology of the brain, the mental deterioration, the action of sedative

drugs, or the effect of ostracism.

3. A very small minority of patients displayed peculiar personality

traits before seizures began. These cases may possibly be looked on as

hereditary and linked with the tendency to seizures or with the hereditary

cerebral dysrhythmia. This possibility will become positive if it can be

demonstrated that the epileptic personality is associated with hereditary

dysrhythmia, and is present in those nonepileptic relatives who have

abnormal brain waves.

4. In many cases peculiar traits are expressions of a cortical dys-

rhythmia. The bad behavior is a seizure.

5. If future research demonstrates that a significant number of per-

sons who have disturbance of personality also have distortion of brain

3 i ] SEIZURE STATES 963

waves, then epilepsy, which is a cerebral dysrhythmia, would have an

intimate relationship to the whole problem of personality and behavior

disorders.

Personality in Migraine. Although migraine has been recognized

by medical writers almost as long as epilepsy, little has been said about

a peculiar personality. Liveing (1873) and other authors emphasize the

importance of emotion in the precipitation of attacks, but apparently the

first claims that persons subject to migraine seizures possessed a peculiar

personality make-up was advanced by Touraine and Draper (1934). A

more detailed analysis of 64 cases has been made also by Wolff (1937,

1940). These workers are in substantial agreement as to the outlines of

the characteristics noted, although Touraine and Draper give them a

greater significance from the psychoanalytical point of view.

Wolff says that the majority of migraine patients as children were deli-

cate, or treated as such, shy, obedient, sober, pliant, and well-mannered.

School work was done conscientiously. They might be both docile and

stubborn. Some were obstinate, argumentative, and disobedient, and

even sullen. Temper tantrums were met with occasionally. Attachment

to the mother was often noted.

Among adults, nine-tenths were unusually ambitious and preoccupied

with achievement ; they attempted to dominate their environment. Al-

most all were conscientious, perfectionist, persistent and exacting, metic-

ulous, fastidious, and at the same time efficient. They dressed neatly;

they were hard working, endowed with energy and push, and inclined

to accumulate responsibilities. They allocated responsibility poorly ; they

must see a thing through personally, which meant intense application and

long hours. Wolff ascribed headaches which occurred during vacations

to loss of satisfaction of achievement. As a rule they loved order and a

system of classification. Punctuality brought satisfaction, but occasion-

ally patients were afflicted with procrastination and had difficulty in

making a judgment. Inflexibility was another prominent characteristic.

Although they were themselves creators of plans and systems, they found

difficulty in adapting themselves to systems imposed on them by others.

They found it difficult to forgive or accept the foibles of others.

As to their attitude toward seizures, they were inclined to disregard

common sense limits and rules when free of headache, but during the

seizure, they tyrannized their family with their distress and needs. They

disregarded the body so long as it functioned properly, but resented

bodily interference with the attainment of their ends. Social relations

were usually cautious and circumscribed, aloof and politic. Many were

thrown into headaches by the anticipation of social intercourse. Sexual

dissatisfaction, usually in the direction of distaste, existed in more than

four-fifths of the women.

It will be seen that these characteristics are qualitatively different and

socially much more acceptable than the personality characteristics which

have been claimed for the epileptic. The migrainous person has many of

964 PERSONALITY AND THE BEHAVIOR DISORDERS [31

the characteristics which make for worldly success. As for the signifi-

cance of these characteristics, Wolff states the personality features men-

tioned are in no sense pathognomonic of migraine, nor are they associated

with migraine alone. These personality traits in certain life situations

are prone to precipitate attacks in persons predisposed to migraine.

The personality make-up emphasized by Wolff represents a certain

type of soil in which the seeds of migraine readily take root. Apparently

this soil is favorable also to the growth of disorders such as gastric

ulcers, hypertension, and asthma, in persons predisposed to them. The

characteristics which have been named might, when exaggerated, be

classified separately as psychoneuroses. Whether migraine therefore

should be called a psychoneurosis or a disorder which is symbiotic with

psychoneurosis is a fine distinction.

The relationship of personality to migraine is not complicated by some

of the factors suggested for epilepsy for brain pathology, social ostra-

cism, continuous use of sedative drugs, and mental deterioration do not

complicate the problem of migraine. The constitutional aspect of per-

sonality is certainly important but has been too little studied. I have

seen four identical twins in which both twins had migraine and both

had similar personalities. A survey needs to be made of the siblings of

migrainous individuals to determine the degree of their infection with

the traits which have been named. Because migraine headaches are not

associated with striking alterations of the electroencephalogram this tech-

nique is not available for comparative studies. Occasionally a person

subject to migraine will experience sharp changes of mood, behavior,

or of personality which seem to substitute for a headache seizure. Some

of these occupy a no-man's-land between psychomotor epilepsy and

migraine.

In the realm of treatment, Wolff proves that much can be attained by

correction of emotional disturbances which lead to headache seizures.

Over W% of his 64 patients failed to secure any improvement ; 28% had

no attacks or only rare ones ; an additional 36% were much improved.

Unless the patient has adopted a suitable new pattern of life, headaches

will recur with new provocation. Both the frequency and intensity of the

attacks can be reduced if patients learn to understand themselves better

and exercise a more intelligent management of themselves. Modification

of the inherited personality make-up is not easy, but with intelligence and

cooperation even inherited characteristics can be modified.

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PART VII

SOME INVESTIGATED CORRELATES OF

BEHAVIOR DISORDER

Chapter 32

PSYCHOLOGICAL DEFICIT

By J. McV. HUNT, Ph.D., and C. N. GOFER, Ph.D.

SOME LOSS OF EFFICIENCY is one of the commonest manifestations of dis-

order or cerebral injury in the human being. This fact is implied in the

allusion to the psychotic as one who has "lost his mind," still common

in popular speech. It is also recognized by such descriptive terms of

psychiatry as dementia and deterioration, and by the interpretative con-

cept of regression. Loss of efficiency also occurs in the aged. With the

recognized prevalence of this loss, it is not surprising that a large pro-

portion of the experimental effort devoted to these conditions has been

concerned with various aspects of the efficiency of affected individuals.

The results of this effort have significant implications for both the nature

of these conditions and for the nature of intelligent behavior. To sum-

marize these results and to show these implications are the tasks of this

chapter.

We have chosen the term deficit to designate this loss of efficiency

because it is a neutral term. Dementia, deterioration, and regression, al-

though more prevalent, have become associated with various beliefs about

the nature of the loss. By dementia Kraepelin (1919) meant a perma-

nent, irreversible loss of intellectual capacity. By deterioration he meant

a progressive change in the direction of less and less efficiency. For the

majority of workers in this field, these definitions prevail today. Regres-

sion has been used in several theoretical systems with different implica-

tions in each. Since we propose to test these various conceptions with

the results of investigation, we prefer a neutral term. Deficit has not

been associated with any such implications. As used here, it is an oper-

ational concept. When any person performs in some situation at a level

of efficiency below that expected from comparison with typical individuals

or from some indicator in his own present or past behavior, that person

manifests a deficit.

Unfortunately for the expositor, the studies in this field are not held

together with any single purpose or theory. The methods vary tremend-

ously. Rarely has any investigator carried out a consistent program, or

even used a single technique, on the whole gamut of clinical conditions.

These facts make it impossible to generalize with certainty. The implica-

Q7i

972 PERSONALITY AND THE BEHAVIOR DISORDERS [32

tions we shall derive from these studies must be regarded as tentative.

We hope, nevertheless, that this chapter will clarify the picture to some

extent, that it will serve as an object-lesson concerning the pitfalls of the

field, and that it will stimulate research in certain promising directions.

We have organized the studies of deficit around the methods employed

and the aspects of function concerned, and we have attempted to bring

the results to bear upon the main problems in the field. We shall con-

sider first those studies using the standard tests of intelligence ; secondly,

the studies of specific aspects of behavior, and thirdly, we shall draw

certain conclusions concerning the nature of the deficit in the various

sorts of conditions and the nature of intelligence. 1

Results from Standard Tests of Intelligence and of Deficit 2

Measuring Deficit. To measure the effects of any condition on

efficiency, whether it be disorder, cerebral injury, or age, should require

on logical grounds that an individual's efficiency be measured before and

after the onset of the condition. In practice this nice logical requirement

has not been feasible. Only very recently has any considerable propor-

tion of the population been given the standard tests of intelligence, and

no investigator, to our knowledge, has been able to obtain predisorder or

preinjury test results from the patients in his sample. For this reason

substitute controls have been devised.

In one of the substitutes, the investigator compares the central tend-

ency (mean or median) of scores or mental ages and the measure of vari-

ability (standard deviation or interquartile range or range) derived from

his sample of patients with similar statistical measures derived from a

sample of "normal" individuals. A second of these substitutes consists

of using the vocabulary of the damaged individual as an index of his

original efficiency. His present efficiency on some other sort of test is

then compared with his vocabulary score to determine the extent of his

particular deficit (Babcock, 1930). A third substitute, devised by Ry-

lander (1939) to measure the deficit caused by surgical injuries to the

frontal lobes, consists of matching each patient with a control of the same

age, same educational record, and same cultural level and occupation. 3

1 Limits of space make it impossible to include everything. Deficit in the epilep-

sies is omitted because Lennox covers the material in Chapter 31. Results from

the feebleminded appear only incidentally for purposes of comparison. Results from

the Rorschach test are included only where they are directly related to those from

other methods because they appear in White's chapter (6) on the projective methods.

2 Reviews of this work appear in several sources: Hunt (1936a), Rouvroy

(1936), Wechsler (1939), Kendig and Richmond (1940), Roe and Shakow (1942).

Since this chapter was written, Brody (1942) has brought out a review in England

which has special significance because it contains a section specifically devoted to

deficit in old age. We are indebted to Roe and Shakow for the use of their mono-

graph in manuscript form, and to Klebanoff (1944) for the use of his manuscript

which reviews the studies of deficit in patients with frontal lobe injuries.

3 In one instance, Roe and Shakow (1942) used also the mental age equivalent

of the educational status of their group of patients.

32] PSYCHOLOGICAL DEFICIT 973

DEFICIT IN TERMS OF MENTAL AGE. Measuring deficit with intelli-

gence tests began with the First World War when the modest contribu-

tions of Binet and Simon were turned into a social movement. Of

the various tests, the Yerkes Point Scale and Terman's 1916 revision

of the Binet scale have been used most commonly. Recently, studies

employing the Wechsler-Bellevue scale, the first ever standardized on

adults, have begun to appear (Wechsler, 1939). These tests yield imme-

diately the relative efficiency of patients, and means of results yield the

relative efficiency of the various diagnostic groups. The deficit appears

as the difference between the mean mental age of each of the various

diagnostic groups and mean mental age of some control group.

Before 1935, investigators were content to compare the mental ages

of their patients with the norms derived from the groups of children on

which the Point-Scale and the Stanford-Binet were standardized. This

introduced age as an uncontrolled variable because the patients were

always adults. In recent studies the investigators have recognized the

necessity for adult control groups. One sample obtained from the white

draft of the First World War yielded an average of 161.04 months of

mental age (Yerkes, 192 1). 4 It is large (653), but overloaded with

young men. Kendig and Richmond (1940) utilized a sample of 217

nurses (median M.A. = 181 months) and a sample of 129 hospital em-

ployees (median M.A. = 156 months). Although these samples are

better than no adult controls, the nurses averaged younger than patients,

and neither group could be considered a random or a representative

sample of the population. Roe and Shakow (1942) used a sample of 65

surgical and orthopedic patients (mean M.A. = 163.6 months) collected

by Weisenburg, Roe, and McBride (1936). Although this group is

small, it was chosen carefully and is satisfyingly representative of the

social, economic, and adult-age categories of our population. Further-

more, it serves to hold the factor of living-in-a-hospital relatively con-

stant. The normal average of mental age appears to be in the interval

160-164 months. Because the various disorders have different age ranges

(see Landis and Page, 1938, p. 37), what is still needed is a sample of

Stanford-Binets from normal adults large enough to allow fractionation

for each of the age decades. For Wechsler's (1939) test, the standard-

ization group supplies just this sort of control.

Measuring deficit by comparing the averages of groups of patients

with the averages of adult control groups would logically require that the

samples of patients and controls be random selections from the groups

represented. Actually a number of selective factors affect these samples

and much of the variation among the averages reported for every diag-

nostic group (see Table I) may be attributed to them. For samples of

paretics the averages range from 128 months of mental age (Wells and

Kelley, 1920) to 152 months (Schott, 1930). For samples of schizo-

4 For purposes of comparison, we have converted the results from all the studies

to months of mental age as they appear in Table I.

974

PERSONALITY AND THE BEHAVIOR DISORDERS

[32

TABLE I

MENTAL AGE IN THE VARIOUS DIAGNOSTIC GROUPS

Number

Diagnostic Group Cases

M.A. in Months Variability

Mean Median S.D. Range

Investigator

Control groups

White draft

653

217

129

65

161.0 160 34.01

181

156

163.6 25.00

66-234

122-224

94-222

96-234

Yerkes(1921)

Kendig & Richmond (1940)

Roe&Shakow (1942)

Hospital employees ...

Surgical and orthopedic

Psychoses considered primarily "organic"

Psychosis with alcoholism:

Chronic 25 126.0

24 129

30 (tf)5 145.9 29.2

Acute 15 150

17 154.2

Pressey (1917)

Kendig & Richmond (1940)

Roe &Shakow (1942)

Jastak(1937)

Roe&Shakow (1942)

General

sis)

paralysis (pare-

Other organic psychoses.

12

16

7

69

35 <K)

24 (n-tf

9

14

128.0

152.5

135.0

132.1

113.4

136.8

115.6

132

31.2

24.3

68-206

62-160

Wells &Kelley (1920)

Schott (1930)

Jastak (1937)

Kendig & Richmond (1940)

Roe&Shakow (1942)

Michaels & Schilling (1936)

Jastak (1937)

Psychoses considered primarily functional

Schizophrenia:

All types

50

126.0

White only ....

22

50

200

36

16

500

429

167.0

125

180

132

138

135

137

143

Colored

66

101

300 (all)

181 (R)

140.6

149.8

126.7

34.5

74-221

74-221

76-192

36-234

61-234

36-202

Pressey (1917)

Wells &Kelley (1920)

Cornell & Lowden (1923)

Wentworth (1923)

Michaels & Schilling (1936)

Jastak (1937)

Kendig & Richmond (1940)

Roe&Shakow (1942)

Sub-types:

Catatonic

51

144

31 (R)

28 (n-R)

11

164.8

140.1

148.0

29.1

35.7

96-117

56-202

32

32 (R)

28 (n-R)

16

129.4

105.1

130.0

138

30.0

36.0

72-197

36-173

38

41

58 (R)

31 (n-R)

38 (R)

171.0

154.8

135.7

144.0

148

33.5

32.0

35.6

82-234

80-190

Manic-depressive psychosis

25 (n-R)

43

23

23

65

19 (R)

18 (n-R)

131.6

171

169

149

166.4

144.6

34.4

148

32.0

34.0

114-222

84-203

Kendig & Richmond (1940)

Roe&Shakow (1942)

Trapp& James (1937)

Kendig & Richmond (1940)

Roe&Shakow (1942)

Rawlings (1921)

Trapp& James (1937)

Kendig & Richmond (1940)

Roe&Shakow (1942)

Wells &Kelley (1920)

Michaels & Schilling (1936)

Jastak (1937)

Kendig & Richmond (1940)

Roe&Shakow (1942)

3 2]

PSYCHOLOGICAL DEFICIT

TABLE I Continued

975

Number M.A. in Months

Variability

Diagnostic Group

Cases

Mean Median

S.D.

Range

Investigator

15

156

Michaels & Schilling (1936)

41

161

Kendig & Richmond (1940)

22 (R)

164.7

25.1

122-211

Roe&Shakow (1942)

9 (n-R)

143.8

80-203

<

Psychopathic personality .

,. 50

159.0

Cornell & Lowden (1923)

38

164.0

Michaels & Schilling (1936)

67

147

Kendig & Richmond (1940)

22 (R)

156.1

29.4

109-234

Roe&Shakow (1942)

14 (n-R)

138.8

23.4

101-193

" "

Psychoneuroses

All types

114

143.0

Hollingworth (1920)

70

144

Tendler (1923)

39

180

Michaels & Schilling (1936)

7

176.0

Jastak (1937)

26

169

Kendig & Richmond (1940)

36(7?)

169.1 28.5

106-234 Roe & Shakow ( 1942)

12 (n-R)

153.1 33.5

108-196 "

256

174.6

Malamud & Gottlieb (1944)

172.0

<

Hysteria

,,,. 177

142.8

Hollingworth (1920)

unstated

162

Tendler (1923)

16

171.0

Roe&Shakow (1942)

unstated

177.0

Malamud & Gottlieb (1944)

Neurasthenia

83

156.0

Hollingworth (1920)

unstated

127

Tendler (1923)

8

147.0

Roe&Shakow (1942)

unstated

169.0

Malamud & Gottlieb (1944)

Psychasthenia

10

178.8

Hollingworth (1920)

unstated

145

Tendler (1923)

3

177.0

Roe&Shakow (1942)

unstated

177.0

Malamud & Gottlieb (1944)

5 Roe & Shakow distinguished between "representative" (R) and "nonrepresentative" (n-R)

examinations, and we give both sets of figures here.

phrenics, they range from 125 months (Wentworth, 1923) to 180 months

(Michaels and Schilling, 1936), and this range particularly is greater

than could be expected from chance fluctuation. The most obvious selec-

tive factors are : nature of the institution, care and aim of the investigator,

variations in diagnostic practices, and the accessibility of patients at the

time of test. Excepting the samples of psychotics reported by Wells

and Kelley (1920), and Schott (1930), and the sample of psychoneu-

rotics by Malamud and Gottlieb (1943) which were out-patients, these

samples came from state hospitals. Several of these samples made no

pretense of being random or representative. Wells and Kelley, and Jas-

tak were primarily interested in the patterns of success and failure to be

reported below, and Schott in the retest variability of paretics. Diag-

nostic practices influence primarily the averages of the subtypes of

schizophrenia. Probably the most important selective factor is the degree

of cooperativeness required at the time of the test. Practices have dif-

fered considerably. Roe and Shakow (1942) have made an honest

976 PERSONALITY AND THE BEHAVIOR DISORDERS [31

attempt to deal directly with this factor by dividing their samples from

the various diagnostic groups into "representative" and "nonrepresenta-

tive" examinations. Their criteria were several. "Representative" per-

formances were characterized by willingness to take the test, interest in

the specific tasks, and freedom from factors of a temporary kind like a

psychotic episode or an emotional upset. Averages are given for both

types of performance, and the deleterious effects of uncooperativeness on

mental age are clearly demonstrated. But which average should repre-

sent the diagnostic group? We should not agree with the implied

assumption that the tests measure any fundamental capacity, and in so

far as the psychosis affects cooperativeness, it affects efficiency. In spite

of these variations, the averages reported by Kendig and Richmond

(1940) and Roe and Shakow (1942), the two most adequate in this

group, agree well for most of the diagnostic groups; e.g., for schizo-

phrenics they are respectively 138 months and 140.6 months for "repre-

sentative" and "nonrepresentative" performances combined.

With these limitations in view, consider the deficits in the various

diagnostic groups (see Table I). If we consider the interval of 160-164

months as the average mental age of the general population, every psy-

chotic group shows a deficit. The results from the Yerkes Point Scale

and the Stanford-Binet, coupled with those from the Wechsler-Bellevue

(Wechsler, 1939, Ch. 6), permit the over-all generalization that the

deficit is largest for the "organic" psychoses, next largest for the "func-

tional" psychoses, and that deficit is probably absent in the psycho-

neuroses.

Among the "organic" psychoses, the deficit is largest for senile de-

mentia and those disorders involving diffuse cortical degeneration such

as Alzheimer's disease and Pick's disease, next largest, approximately 30

months, in paretics, and smallest in psychosis with alcoholism. The

samples of alcoholics vary considerably and overlap with schizophrenia.

Alcoholics with Korsakoff's syndrome (Wechsler, 1939) show great loss ;

chronic groups average from 126 months (Pressey, 1917) to 146 months

(Roe and Shakow, 1942), while acute groups average around 150

months.

Among the "functional" psychoses, schizophrenia shows the greatest

average deficit, approximately 20 months, with considerable variation

among the subtypes. Paranoia and psychopathic personality are second

with averages approximately 10 months below the control average. The

averages for the manic-depressive group vary from 148 months (Kendig

and Richmond, 1940) to 171 (Wells and Kelley, 1920), and these varia-

tions probably reflect variations of psychometric practice. In some hospi-

tals patients are often tested while psychotic behavior is prominent,

while in others they are tested only when psychotic behavior has reached

a minimum. Roe and Shakow obtained the high average of 166 months

from tests given when patients were quiescent, and therefore, the figures

of Jastak (148 months) and Kendig and Richmond (149 months) prob-

ably reflect the effects of this psychosis more adequately.

32] PSYCHOLOGICAL DEFICIT 977

The variation among the averages reported for each of the subtypes

of schizophrenia may well reflect differences in diagnostic practice. Hebe-

phrenics, however, consistently show the largest deficit which is approxi-

mately as great as that found in general paralysis. The "unclassified"

group at Worcester (Roe and Shakow) is a close second. The catatonic

and paranoid subtypes show the least deficit. Agreement is poorest for

the simple subtype. Most of the averages reported for psychoneurotics,

on the other hand, are above the norm. Those reported more recently,

especially those from Malamud and Gottlieb (1944) who had a sample

of 256 patients, contradict the conclusion that psychoneuroses develop

in persons of subnormal intelligence. This latter conclusion derives from

the older work of Hollingworth (1920) and Tendler (1923) whose

averages are exceptionally low.

The effects on mental age of having parts of the brain removed sur-

gically are somewhat equivocal. When we converted the results from the

Stanford-Binet (1916 or 1937 revisions), or from related tests, to men-

tal age in months for nineteen cases reported in the American literature,

we obtained the remarkably high average mental age of 202 months,

range 153 to 251 months. Of these nineteen, fourteen operations con-

cerned the frontal lobe, four the temporal, and one the occipital lobe.

Moreover, T. Hunt's psychometric studies with the Stanford-Binet of

psychotic cases treated by prefrontal lobotomy yielded no evidence of

post-operative deficit (Freeman and Watts, 1942, Ch. 14). From such

evidence, Hebb and Penfield (1940) have argued that the excessive

deficit found in the "organic" disorders, commonly attributed to cerebral

damage, is probably more a matter of diseased cerebral tissue than of

the absence of tissue. This may be true, but on the other hand, one

should not conclude from these data that these operated cases suffered

no deficit. For instance, one reported by Nichols and Hunt (1940) had

a consistent IQ of 120, in four tests, but he failed at double alternation,

showed great "rigidity of abstract attitude" on the Vigotsky test and

exhibited other deficiencies. Such tests as the Stanford-Binet are inade-

quate to uncover deficit in many of these cases following brain operation.

Nevertheless, Ry lander (1939) did find reduced mental ages with Hell-

strom's Swedish translation of the Stanford-Binet in 32 cases whose

frontal lobes had been surgically damaged. His technique of matching

each patient with a control from the same environment of about the same

age, occupation and education is superior to comparing group averages.

Where "large" excisions from the left frontal lobe were involved, the

average difference was 16 points of IQ; for "small" excisions from this

lobe, 4.3 points (p. 289). A conversion of his reported IQ's to mental

age in months yields an average of 168 months for controls and an

average of 151 months for operated cases, range 110 to 195 months.

This average loss of 17 months contrasts sharply with the results from

6 These figures were computed from the test results in case-studies reported by

Ackerly (1933), Brickner (1936), Rowe (1937), Halstead (1940), Hebb (1939a,

1939b, 1941), Hebb and Penfield (1940), Nichols and Hunt (1940).

978 PERSONALITY AND THE BEHAVIOR DISORDERS [32

the American studies. The original mental ages of the American patients

were probably much above average.

Inferring deficit from comparing the averages of diagnostic groups

with those of control groups representative of the normal population

assumes that the various diagnostic groups select victims randomly from

the population. Indirect evidence from rate-studies argues against this

assumption. Terman (1940) found the proportion of disorders in his

group of gifted children, restudied after sixteen years, lower than that

for others of their age. Rosanoff (1938) has reported psychoses to be

three times as common in illiterates as in literates. Paris and Dunham

(1939) found the highest rates of incidence for all the diagnostic groups,

excepting the manic-depressive psychosis, in those urban areas where

one would expect test-performance to be below average. Babcock ( 1933) ,

and Kendig and Richmond (1940) considered their samples of schizo-

phrenics below average in education, but they appear to have failed to

consider the factor of age in determining the years of education to be

expected. On the other hand, Roe and Shakow (1942) point out that in

the 723 schizophrenics (mean age 38.1 years) admitted to Massachu-

setts hospitals in 1935, the educational distribution was 66% grammar

school, 29% high school, and 6% college. This corresponds closely to

the distribution of 65% grammar school, 25% high school, and 10%

college reported for normal individuals in the thirties by Shakow and

Goldman (1938). Simmins (1933) found the vocabulary scores of her

cross-section of 200 psychotics distributed similarly about an average

approximating that for normal adults. Wiersma (1930) has claimed that

the prepsychotic intelligence of paretics is normal. The fact that the

manic-depressive patients in these studies have approximately a normal

average mental age refutes Duncan's (1936) argument that mental de-

ficiency is an important etiological factor in this disorder.

A decline in mental age with age after the twenties argues against

attributing entirely to these disorders the larger deficits shown from the

"organic" groups where the patients are older. Yerkes (1921) found

that officers in the sixth decade averaged about 18 months of mental

age below those aged 20 to 25 years. The parents of Willoughby's (1927,

1929) sample of 110 children showed a decline to a "pubertal or pre-

pubertal level" of mental age at age 60. Jones and Conrad (1933) found

the peak of mental age in the group aged 18 to 21 years and a gradual

decline to 168 months by age 55. Weisenburg, Roe, and McBride

(1936) found low negative correlations between test-scores and age in

their carefully selected sample of adults. When Wechsler (1939) stand-

ardized the Wechsler-Bellevue test on a sample of several thousand sub-

jects he found that mental age declined about 12 months a decade. For

this reason he condemned the calculation of an adult IQ with the same

basal denominator for all ages, and presented a table of denominators

which descends from 15.5 years of mental age for ages 20 to 24 to 12.0

years for ages 50 to 59. Since the "organic" groups average consider-

ably older than the "functional" groups, some of the difference in

32] PSYCHOLOGICAL DEFICIT 979

the size of deficit shown by the tests is attributable to processes of

aging.

THE BABCOCK METHOD. The clever but questionable technique of

using the vocabulary score as an index of original "capacity" was origi-

nally devised by Babcock (1930) and later revised (1941). Studies of

passes and failures on the test items in the Stanford-Binet scale (see

review by Harris and Shakow, 1937) had shown that vocabulary scores

remain consistently high for patients suffering from nearly all the dis-

orders. The common occurrence of the loss of recent memory in various

diseases affecting brain tissue coupled with the findings of Franz that the

ablation of cerebral tissue damages primarily new habits in animals had

led to the conclusion that cerebral insults damage primarily habits re-

cently acquired. With these two lines of evidence and this conclusion in

view, Babcock devised a series of tests, emphasizing information, speed

of performance, and ability to learn, to measure efficiency. These she

standardized on normal individuals and so arranged the scoring that the

average discrepancy between their actual scores on the efficiency tests

and those predicted from vocabulary scores approximated zero. Thus, in

a disordered individual, this discrepancy, which she termed an "efficiency

index," would serve as a measure of the deficit. If the assumptions are

valid, this method enables one to estimate not only the average deficit

of a diagnostic group but also the deficit in any individual, and there-

fore, to determine also the variability of the deficits incurred in any

disorder.

The results obtained by investigators who have employed the Bab-

cock test appear in Table II. From top to bottom in the table are the

averages and variabilities of the efficiency indices for groups of normal

individuals, to serve as a statistical standard, and for the various diag-

nostic groups for which results have been reported.

Numerically adequate samples are available of normal individuals, of

aged normal individuals, and for the diagnostic groups : paresis, schizo-

phrenia, psychosis with alcoholism, and drug addiction. On the whole

the averages from the available samples of patients in any diagnostic

group agree well. Wittman's exceptionally high average from a small

sample of schizophrenics may well be disregarded. Again by this method

the deficits average larger for the "organic" groups, excepting the

alcoholics and the drug addicts who are not psychotic, than they do for

schizophrenia. On the other hand, the deficits of individuals with schizo-

phrenia vary more than do those of any other diagnostic group save

possibly the epileptics (Wittman, 1933). Thus, in the data available,

the largest individual deficits, measured in terms of the efficiency index,

appear in schizophrenics. The variability among the average efficiency

indices for normal groups is attributable to age. Gilbert (1935) found

an average index of zero in her sample of normal individuals in the

twenties, which agrees with Babcock's standardization, but her sample

of normal individuals in the sixties shows an average index of 4.8, a

PERSONALITY AND THE BEHAVIOR DISORDERS

[3*

TABLE II

DEFICIT IN VARIOUS DIAGNOSTIC GROUPS IN TERMS OF AVERAGES

OF BABCOCK'S "EFFICIENCY INDICES"

Diagnostic

Groups

Number Efficiency Indices Variability

Subjects Mean Median S.D. Range

Investigator

Control groups

264 0.00 +0.1

228 -fO.5

26 -1.20

Age 20-29 185 0.00

Age 60-69 175 4.80

Psychoses considered primarily organic

General Paralysis (paresis):

All 75

Improving 42

Not Improving 33

1.18

All

Psychoses with organic brain

disease

Psychoses with cerebral arte-

riosclerosis

Psychoses with alcoholism...

Psychoses with epilepsy

98

4

66

26

-4.68

-4.12

-5.40

-5.10

-4.8

-4.0

-5.3

2.02

2.01

1.79

-3.3

-4.9

2.3

5.4

Psychoses considered primarily functional

Dementia praecox (schizo-

phrenia) 124

24 -0.8

110 -3.4

Hospitalized drug addicts

(abstinent for 6 months) 156 2.28

-3.5

1.64

3.4 to +3.2

5.2 to +2.1

5.8 to -2.5

6.7 to -4.0

9.0 to +0.3

Babcock (1930)

Babcock (1933)

Wittman (1933)

Gilbert (1935)

Gilbert (193 5)

Babcock (1930)

Babcock (1930)

Babcock (1930)

Wittman (1933)

- 5.2 to -1.7 Wittman (1933)

- 6.1 to -3.7 Wittman (1933)

4.2 to +1.4 Wittman (1933)

-10.2 to +1.1 Wittman (1933)

-13.1 to +0.5 Babcock (1933)

-7.3 to +1.7 Wittman (1933)

- 8.3 to ? Schwarz (1932)

Partington (1940)

deficit as large as that shown by Babcock's paretic group. Still further

evidence from this association between increasing age and decreasing

efficiency indices on the Babcock test appears in the work of Roe and

Shakow (1942) where the size of the average negative indices in psy-

chotic groups correlated .59 with their mean age. At least part of the

low efficiency of the "organic" groups must be attributed to aging rather

than to the disorders as such. Age selectivity may account for the low

average index of Wittman's (1933) sample of controls, and perhaps for

the relatively high average index for her small group of schizophrenics.

Babcock's (1930) finding that persons with indices below 2.0 had

adjustive difficulties, and her conclusion, that an index below 3.5 is

pathological, can be applicable only to young adults.

Since Babcock initiated the use of vocabulary to estimate original

capacity, a number of investigators have reported discrepancies between

vocabulary scores and scores on various sorts of other tests. The aver-

age discrepancies between months of mental age on the Stanford-Binet

without vocabulary and on Terman's vocabulary reported for various

normal and disordered groups appear in Table III. Considerable varia-

tion marks the averages reported for most of the groups. Age selec-

tivity probably accounts for the variation from 11 months (Roe and

Shakow, 1942) to +10 months (Kendig and Richmond, 1940) in the

32] PSYCHOLOGICAL DEFICIT 981

samples of normals. This discrepancy has been shown to increase with

age by Shakow and Goldman (1938) and by Roe and Shakow (1942)

who found it increasing from an average of 4 months for controls in

their twenties to 27 for those in their fifties. The variation from a

mean of 30.4 (Davidson, 1937) to a median of 2 months (Kendig

and Richmond, 1940) in the results from schizophrenic groups is prob-

ably a statistical artifact, because the extremely large negative discrep-

ancies do not affect the median as they do the mean. The interesting

facts brought out by Kendig and Richmond are that large positive dis-

crepancies may appear for individual schizophrenics and that half this

group shows no discrepancy at all. Except for the psychoneurotics whose

average discrepancies are normal, all the diagnostic groups show some

evidence of deficit. But by this method the deficit in the "organic"

groups appears little larger than that in the "functional" groups.

Vocabulary scores have been compared with scores on a battery of

the "visual-perception-tests," like those Spearman has used to measure

general ability (#), by Simmins (1933) to measure what she termed

"^/-deterioration" in psychotics. She found the discrepancies between

these scores correlated with the judged severity of disorder, but she

reported no averages for the various diagnostic groups. Harbinson

(1936) has extended Simmins* work and found little evidence of deficit

in 36 patients from a hospital treating only the acutely disordered.

Shipley (1940) has recently devised a test that measures deficit in

terms of a discrepancy between scores on vocabulary and tests of

"abstract" ability which require the subject to discern and to continue a

system in a series of items. The discrepancy is expressed as a "conceptual

quotient" (CQ) which is virtually "abstraction age" divided by "vocabu-

lary age" (Shipley and Burlingame, 1941). The CQ's of psychoneurotics

approached those of normal subjects. Those of patients with "functional"

psychoses were lower, and of these, schizophrenics fell below manic-

depressive patients. Those of patients with "organic" psychoses were

lowest of all. The median of those in private hospitals (JV-85) was 20

points above the median of those in state hospitals. This test is recom-

mended by the fact that the self-administering procedure is used for both

vocabulary and "abstract" ability, but unfortunately the control group on

which it was standardized contained only children and young adults. The

age factor undoubtedly complicates the results from both Simmins's and

Shipley's variations of the Babcock method.

Despite the comparative advantages of the Babcock method mentioned

above, several factors besides age complicate the significance of these dis-

crepancy scores as measures of deficit. First, vocabulary performance is

an imperfect indicator of ability as is shown: by the fact that the dis-

crepancy between mental age on Terman's vocabulary and mental age on

the other tests of the Stanford correlate negatively with mental age

(Altman and Shakow, 1937), and by the fact that feebleminded indi-

viduals exhibit an "unquestionable tendency toward lower CQ's" (Ship-

PERSONALITY AND THE BEHAVIOR DISORDERS

[32

TABLE III

DISCREPANCY BETWEEN MENTAL AGE EQUIVALENTS FOR THE TERMAN

VOCABULARY TEST AND MENTAL AGE ON THE OTHER STANFORD-

BINET TESTS IN VARIOUS DIAGNOSTIC GROUPS

Discrepancy (mo.) Variability

Group Number Mean Median S.D. Range

Investigator

Control groups

Unselected 200 3.6 17.3 Davidson (1937)

86 5.0 Airman & Shakow (1937)

Nurses 217 +3 42 to +43 Kendig & Richmond (1940)

Employees 128 +10 44 to +49

Surgical cases 65 11.0 Roe & Shakow (1942)

Delinquent groups

Prisoners 308 15.0 Fry (1930)

Delinquents 150 19.0 Shakow & Millard (1935)

56 12.0 Altman& Shakow (1937)

Psychoses considered primarily organic

Paresis 7 34.4 Jastak (1937)

35 27.0 Roe & Shakow (1942)

With alcoholism ... 15 3.7 Jastak (1937)

Chronic 30 19.0 Roe & Shakow (1942)

Acute 17 22.0

Other organic psy-

choses 14 25.6 Jastak (1937)

Psychoses considered primarily functional

Dementia praecox

(schizophrenia) .. 71 30.4 24.4 Davidson (1937)

16 19.0 Jastak (1937)

477 - 2 -76 to +51 Kendig & Richmond (1940)

181 -19.4 (fl)5 Roe & Shakow (1942)

Manic - depressive

psychosis 23 19.0 Jastak (1937)

19 -18.0 (#) Roe & Shakow (1942)

Paranoid condition.. 41 12 66 to +26 Kendig & Richmond (1940)

22 19.0 Roe & Shakow (1942)

Psychoneuroses

7 - 2.4 Jastak (1937)

36 4.0 Roe & Shakow (1942)

5 See footnote on page 975.

ley and Burlingame, 1941). Secondly, the vocabulary-performance may

suffer as a consequence of disorder as shown : by the fact that mental age

on vocabulary tests in paretics and hebephrenic schizophrenics falls con-

siderably below mental age derived from educational level (Roe and

Shakow, 1942), and by the fact that vocabulary scores themselves corre-

late positively with clinical estimates of deterioration (Capps, 1939).

Thirdly, the verbal administration of vocabulary tests, involved in all but

Shipley's test, requires less in the way of self-direction from the subject

than is required in the other modes of administration. Yacorzynski

(1941) has pointed out that oral presentation allows for a number of

methods of defining a word or item passably that are of unequal diffi-

culty. Further evidence for this criticism derives from the fact that

psychotic patients consistently do better on Kent's Oral Emergency Test

than they do on the Stanford-Binet (Elwood, Burchard, and Teagarden,

1937), and from Hunt's unpublished finding that schizophrenic patients

32] PSYCHOLOGICAL DEFICIT 983

particularly can be prodded into several times their customary output

when the experimenter supplies direction.

While these quantitative test results demonstrate the existence of

deficit in most of the psychoses, in aged people, and in individuals who

have suffered surgical brain injury, the quantitative results themselves

are relatively uninformative. Even as measuring instruments, the tests

are only pseudo-quantitative. Such pseudo-units as "months of mental

age" or points of "efficiency index" have no clear equality, and no zero

for intelligence exists. A rigorous quantitative approach to intelligence

and deficit still remains for the future. The "speed" factor might readily

be quantified by measuring time required to do various kinds of tasks.

For the "power" aspect the way is not so evident. In connection with the

studies on "thinking" in the "organic" disorders, we shall suggest uti-

lizing the number of "lines of activity" that an individual can synthesize

into a coordinated performance as one possibility for exploration.

Qualitative Results from Intelligence Tests: Is Deficit General

or Specific?

"SCATTER." Considerable attention has been given to the scattering

of successes or failures over the year-levels of the Yerkes Point Scale

and the Stanford-Binet. Nine different measures of this "scatter" have

been devised. Harris and Shako w (1937) have classified these into three

types. The simplest type, range of "scatter," consists in counting the

year-levels over which both successes and failures occur (Wells, 1927;

Shipley, 1934). A second type emphasizes area and consists in the num-

ber of months of credit earned above the basal year (Wallin, 1922).

The third type takes both into account, and the most successful of these

consists of multiplying failures below and passes above the mental age

by the number of year-levels separating each test from the mental age

(Pressey & Cole, 1919). Several investigators have reported greater

scatter in the performances of psychotic patients than in the perform-

ances of normal or feebleminded children, and the greatest scatter ap-

peared in those of "organic" groups. 7 Some of them have suggested that

excessive scatter is a useful diagnostic sign, but the use of children for

controls, and failure to hold mental age constant, vitiated their results.

Kendig and Richmond (1940) have shown, for instance, that many of

the tests in the 1916 revision of the Binet show a different degree of diffi-

culty for adults than for children. Harris and Shakow (1938) compared

the scatter, measured by four different methods, of matched groups of

154 schizophrenic, 133 normal, and 138 delinquent adults. Only mental

age was related significantly to scatter. When mental age was held con-

stant, any differences between the groups disappeared. Kendig and

Richmond (1940) found the median of scatter ( Pressey 's measure)

approximately the same in their schizophrenics as in their controls, but

7 See: Pressey (1917), Curtis (1918), Pressey and Cole (1919), Wells and

Kelley (1920), Wallin (1922, 1927), Porteus (1922), Malamud and Palmer

(1938).

984 PERSONALITY AND THE BEHAVIOR DISORDERS [32

the range was considerably greater in the schizophrenics than in any of

the other groups. They also found scatter related to mental age; the

largest scatter occurred in the middle range of mental ages, and the

feebleminded with low mental ages showed less scatter than schizo-

phrenics. Unfortunately, neither of these investigations included patient?

with "organic" disorders where the earlier investigators found the

greatest scatter. If they really existed, large scatter scores would imply

that the deficits of psychotic patients were selective for particular kinds

of performance, but the scatter approach appears now to be a blind alley.

KINDS OF TESTS SELECTIVELY FAILED. The early work on scatter

and interest in the nature of deficit have led to item-analyses of psychotic

test-failures with the aim of inducing the qualitative characteristics of

deficit from an inspection of the nature of the tests failed. The method has

usually consisted in comparing the percentage of failures on each test in

the psychotic groups and the control groups. When mental age is not

controlled, more psychotics than normal subjects fail all the tests, but

the differential is smallest for vocabulary (Kendig and Richmond, 1940).

Only these results agree with the conclusion of Hart and Spearman

(1914), derived from a correlation analysis of psychotic test results, that

the deficit in all psychotic groups is of diffuse character, involves all

types of activity, and yields a result essentially like feeblemindedness.

When mental age is held constant, selectivity appears. We have tabu-

lated the results obtained from ten investigations using the Yerkes Point

Scale or the 1916 revision of the Stanford-Binet on schizophrenics, for

whom the most data are available, and found a majority agreement con-

cerning selective failure on twelve of the tests. In the Stanford-Binet

these tests are: social comprehension (VI 1 1-3 and X-5), finding similari-

ties (VIII-4), giving date (IX-1), arranging blocks in order of weight

(IX-2), digits backwards (IX-4), absurdities (X-2), drawing designs

from memory (X-3), defining abstract words (XI 1-2), interpreting

fables (XII-5, XVI-2), problem questions (XIV-4). 8 Schizophrenics

are consistently superior to nonpsychotics of similar mental age on

vocabulary tests, and they are usually superior on such tests of infor-

mation as distinguishing between president and king (XIV-3). Rabin

(1941), using the Wechsler-Bellevue, found schizophrenics much su-

perior to nurses of the same mental age on tests of information and

arithmetic, while nurses were much superior on "digit-symbol substitu-

tion" and "object assembly."

Interpretations of the nature of the abilities involved in these tests

selectively failed and passed by schizophrenics, and also by "organic"

patients, have varied considerably. The failures have sometimes been

8 These ten investigations are: Pressey (1917), Wells and Kelley (1920),

Rawlings (1921), Wentworth (1924), Altman and Shakow (1937), Piotrowski

(1937), Collins, Atwell, and Moore (1938), Malamud and Palmer (1938), Kendig

and Richmond (1940), and Roe and Shakow (1942). Methods of comparing and

the nature of the control groups differ considerably in these studies, but these

differences only add to the validity of the results where agreement occurs.

32] PSYCHOLOGICAL DEFICIT 985

explained by assuming the loss of fundamental capacities : the capacity

to generalize and to conceptualize (Rawlings, 1921; Wentworth, 1924;

Moore, 1930; Roe and Shakow, 1942), the capacity to work rapidly,

and that to form new associations and acquire new skills (Babcock,

1930, 1933, 1941). Others have emphasized capacity less and have em-

phasized more the role of "control" and motivation. 10 This emphasis is

implied in such concepts as "defective directional control of thought,"

egocentric preoccupations, and "failure to draw upon information beyond

that in the directions given" (Piotrowski, 1937a). As do many of the

writers in this latter group (footnote 10), we incline toward assuming a

loss of capacity in "organic 1 ' patients, particularly in those with cerebral

lesions ; and for schizophrenics and for the other "functional" psychoses,

we incline toward assuming defective motivation and control of per-

formance. The selective superiorities of psychotics have been explained

as old habits, acquired when capacity was intact, that are undamaged by

lesions because of their age. They are also explained as being the kinds

of tasks that require little in the way of sustained voluntary effort. Again

we incline toward the former view for "organics" and toward the latter

view for schizophrenics. We shall present evidence for these inclinations

below.

We might expect patterns of selective failure and success to differen-

tiate to some extent patients with "organic" disorders from those with

schizophrenia. Damage to cerebral structure should reduce fundamental

capacity, while the "withdrawal" of schizophrenics should leave basic

capacities untouched but alter such functions as judgment. Differences

in performance are actually relatively few, but those few tend somewhat

to corroborate this hypothesis. Common to both types of patients are:

superiority over nonpsychotics of similar mental age on vocabulary and

information, and inferiority on such conceptual tests as interpreting

fables (XII-5 and XVI-2), noticing absurdities (X-2) 11 and finding

9 We would argue that no intelligence test measures any fundamental capacity.

Into the determination of test-performance goes a complex of factors: capacity,

past experience, present motivation, etc. Ideally one can abstract capacity from this

complex, but to do it operationally is very difficult. To show the absence, or the

loss, of the capacity for a given performance, it is necessary to show that the

organism concerned cannot learn, or relearn, the performance with the best of

motivation. The conclusion here mentioned derives from classifying the tests on

the Binet scale according to the apparent nature of the processes involved. The

majority of the tests failed fall into the following categories of Roe and Shakow:

"conceptual thinking," "sustained associative thinking," and with a few in the class

of "immediately learned." Kendig and Richmond attempted to use Spearman's

dichotomy of eductive and noneductive tests, but they discarded it when they

found vocabulary and information, on which patients are selectively superior, in

the former group. If this conclusion is accepted, capacity must be considered synony-

mous with performance. In spite of the difficulties involved, we prefer to maintain

a distinction between these concepts.

10 See: Gatewood (1908), Wiersma (1930), Jastak (1934), Line and Griffin

(1935), Malamud and Palmer (1938), Kendig and Richmond (1940), Rabin (1941),

Yacorzynski (1941), and Brody (1942).

11 Paretics do discern absurdities, however, even without the instruction to look

for them, if they are clearly based on past experience, as are "fir trees with leaves"

and "harvesting in March," and do not involve abstractions. They usually miss, for

986 PERSONALITY AND THE BEHAVIOR DISORDERS [32

similarities, and on tests of sustained associative thinking. Common to

both types also is the general pattern : highest scores on vocabulary, next

on verbal tests, and lowest on performance tests ( Jastak, 1937 ; Piotrow-

ski, 1937b). Roe and Shako w found no significant difference between

paretics and hebephrenics on any of the tests in the Stanford-Binet. On

the other hand, others have found differential patterns (Wiersma, 1930;

Wechsler, 1939, p. 68; Rabin, 1941). Malamud and Palmer, in a direct

search for differences, have shown that "organic" patients are differen-

tially and selectively inferior to feebleminded subjects of the same mental

age range on counting from 20 to 1 (VIII-2) and four digits backward

(IX-4), while schizophrenics are inferior on social comprehension

(VIII-3 and X-5), interpreting pictures (XII-7) and problem ques-

tions (XIV-4). They considered that pathological perseveration and

disturbances of memory underlay the differential failures of the "organic"

group, and that schizophrenics fail differentially on tests "most heavily

dependent on practical judgment." If these results are reproducible, they

constitute an important rinding, for the responses on these particular

tests failed by schizophrenics are clearly scored in terms of social stand-

ards. There is no intrinsic "tightness" to the answers demanded in the

standardization. In so far as schizophrenia consists in an active with-

drawal from social interaction, such are precisely the sort of tests schizo-

phrenics should fail differentially. "Organic" patients should not fail

them, for these tests appear to require relatively little conceptual capacity

or new learning, and the old social habits upon which the correct re-

sponses are based are relatively untouched by cerebral damage (see also

Font, 1940). The common successes and failures of these two groups of

patients may be explained by assuming that reduction of fundamental

capacity and reduction of motivation have similar effects on many per-

formances. Roe and Shakow's finding that uncooperativeness affects

primarily tests involving conceptual thinking and sustained associative

thinking tends to corroborate this assumption.

Several sorts of test-results argue against the loss of fundamental

capacity in most schizophrenics. Malamud and Palmer found a differ-

ential superiority of schizophrenics on arithmetic reasoning. They con-

sidered this superiority illusory, but schizophrenics have also been shown

clearly superior to paretics on arithmetic progressions (Hunt, 1935),

and Rabin (1941) and Magaret (1942) found that performance on

arithmetic tests held up better in schizophrenics than in Wechsler's old-

age group. Piotrowski's (1933, 1937a) finding that even schizophrenic

children, aged four to ten, earn better vocabulary scores than feeble-

minded children of the same mental age argues indirectly against such

loss, for it would appear that vocabulary building goes on in spite of the

disorder. His finding that schizophrenic children improve more on re-

instance, "Since the rabbit ran faster than I did, I could overtake it only slowly

and finally caught it." Schizophrenics do not note absurdities without instruction

to look for them, and then they note the more abstract ones like the latter (Hunt,

1935. and unpublished data). See section on thinking below.

32] PSYCHOLOGICAL DEFICIT 987

testing than do the feebleminded argues the same way. Kendig and

Richmond found that as schizophrenics recovered their test-performance

improved, and only 43% of a group selected because they had been hos-

pitalized more than five years (average of ten years) retained their

original level of performance or improved when retested. Stephenson

(1932b) has shown scores on </-tests to be correlated with /^-scores in

schizophrenics but not in "organic" patients, the higher the /^-scores the

lower the (/-scores. Muhl's (1930) success in getting schizophrenics who

appeared utterly confused to give accurate answers to questions about

time in the hospital and names of attendants and doctors by means of

automatic writing, and the common clinical observation that catatonics

after some recovery can relate incidents that occurred during a stuporous

phase of the psychosis both argue against any loss of impressionability.

Although gross figures from the recent studies of shock-therapy on test-

performance are confusing (Shipley and Kant, 1940), certain specific

findings are suggestive. Wechsler, Halpern and Jaros (1940) found

that patients showed the greatest improvement in the following : number

of vocational interests indicated, counting by threes (1, 4, 7, etc.), find-

ing similarities, and a directions-test. They considered these tests of

interest in the external world, of sustained effort, and of thought con-

trol, respectively. Wittman and Russel (1941) found a high positive

correlation between improvement in efficiency and "attitude" changes.

Thus the tentative generalization can be made that if interest and atti-

tude improve, test-performance improves. 12

The pattern of deficit in the aged, and in cases of adult brain injury

that does not strike the speech areas, resembles generally the pattern

found in the "organic" psychoses. This is Wechsler's (1939, Ch. 6)

conclusion from finding that the aged show the greatest decline on : re-

peating digits forward or backward, arithmetic reasoning, digit-symbol

substitution, picture arrangement, block-design, and finding similarities ;

and the least or no decline on: vocabulary, information, comprehension,

object-assembly, and picture completion. Magaret's results (1942)

agree essentially with these. Jones and Conrad (1933) point out that at

12 In the future, comparisons of the amount of improvement in test performance

in paretics and schizophrenics with fever- and shock-therapy respectively may yield

evidence on this point. Dubois, Mays, and Landis (1934) found a gain in average

score on the Army Alpha from 48 to only 68 in 16 paretics, and attributed part of

this gain to becoming accustomed to the test situation. In the only study of Binet

performance of paretics (7V-78) before and after fever-therapy that we know, 22

improved 10 points or more in IQ, 11 decreased 10 points or more, and 45 showed

no significant change. Epstein and Solomon (1939) concluded that paretics are

unlikely to recover their previous level if the IQ is much lower before treatment

than would be expected from their occupational and educational status. Comparable

results are not available for schizophrenics, but Graham (1940) has reported

improvement in total score, decreased scatter, and a slight shift in the Malamud-

Palmer pattern toward the "organic" after insulin-therapy. The ^fact that Bolles,

Rosen, and Landis (1938) found the more clinical improvement in schizophrenics

showing the better performances on the sorting tests suggests that shock-therapy

is most effective in patients with the "categorical attitude" intact. Whether or not

this indicates a loss of fundamental capacity in schizophrenia depends upon one's

interpretation of the nature of the "categorical attitude.

988 PERSONALITY AND THE BEHAVIOR DISORDERS [32

the sixth decade 40% of the Army Alpha score is derived from "vocabu-

lary" and "general information" which contribute only 10% of the score

at age ten. Miles (1933, 1935) found the greatest deficit in the aged in

tests involving "speed, organization and recall of unfamiliar material and

difficult logical procedures involving a relatively wide memory span."

Gilbert's (1935, 1941) results with the Babcock test and others agree

with these of Miles. The amount of deficit that occurs with aging, how-

ever, appears to be negatively correlated with original ability (Wiersma,

1930; Gilbert, 1935, 1941; Shakow and Goldman, 1938). For cases of

adult brain injury outside the speech-areas, Hebb (1942), summarizing

the literature and his own results, describes a similar pattern of success

and failure on the Stanford, and points out that they also show vocabu-

lary highest, verbal tests intermediate, and performance tests lowest,

which is Jastak's (1937) pattern for the "organic" psychoses. On the

other hand, in cases of brain injury during infancy, Hebb (1942) has

shown that this latter pattern is reversed to one like that in the feeble-

minded : performance tests high, verbal tests and Binet low, and mental

age on vocabulary considerably below chronological age. From these

results he concludes that development and retention of the abilities meas-

ured in tests depend upon the brain in different ways, and "more cere-

bral efficiency or more intellectual power is needed for intellectual

development (acquiring intellectual skills) than for later functioning at

the same level" (Hebb, 1942, p. 286). Brody (1942) argues in similar

fashion, and concludes that the superiority of mature individuals in social

and occupational competence is a function of knowledge and habituated

skills. We shall develop this point further in the conclusion of this

chapter.

INTERRELATIONS AMONG STATISTICAL FACTORS. Investigators in the

English school of factor-analysis have attempted to show the nature of

the deficit in various disorders in terms of Spearman's factors : general

ability g, perseveration />, fluency /, will w 9 and speed. Jones

(1928) found perseveration, measured in terms of performances like

the rate of turning required for color-fusion or ratio between output on

an habituated task (like writing Z's for 30 seconds) and output on an

unhabituated modification of the same task (like writing Z's reversed

for 30 seconds), abnormally high in both manic and depressed patients.

From these data he questioned Wiersma's conclusion that p is abnormally

low in manics. Stephenson (1932a) has found /^-scores higher than nor-

mal in all diagnostic groups, but highest in the depressed. Schizophrenics

gave both very high and relatively low /^-scores, and the scores changed

with variations in the patients' clinical condition. High /^-scores were

associated with inaccessibility and low g, as measured by visual-percep-

tion tests devised by Line (Stephenson, 1932b; Stephenson, et al.,

1934). No such correlation appeared in the performances of "organic"

patients, so Stephenson questioned whether low ^-scores indicate de-

mentia in schizophrenics and argued that the high />-scores might result

32] PSYCHOLOGICAL DEFICIT 989

from Pavlovian inhibition seen as the interference between patterns of

response. Tests of "fluency," such as number of words given in 3 min-

utes or number of things mentioned to be added to an unfinished picture,

normally correlated positively with #-tests. But in cases of manic-

depressive psychosis, Stephenson, et al. (1934) found that manics low

in g were high in /, that cases relatively normal occupied relatively the

same position on both g- and /-tests, and that the depressed had /-scores

relatively lower than their ^-scores. Tests of "fluency" distinguished

manics from the depressed better than speed tests. Fluency appeared low

in cases of anxiety. From a classification of 77 female patients with

"functional" disorders in terms of /- and p-scores combined, cases of

hysteria showed consistently low /-scores but either low or high />-scores ;

manics were characteristically high in / and low in p ; and schizophrenics

were distributed in all four of the possible combinations. Too little of

this sort of work has been done to allow a systematic picture, but the

method appears promising.

In Canada, Line and Griffin (1935) (see also Line, Griffin, and An-

derson, 1935) have initiated a program to differentiate the abnormal in

terms of statistical factors derived from a wide range of performances.

They administered a large battery of tests, including those mentioned

above, the Rorschach, word-association, and the Bernreuter, to 50 indi-

viduals over a range of "stability" from "good students" to psychotics,

and made a factor analysis of the results. Two factors appeared. Fac-

tor I, indicated by positive loadings with word-association, oscillation,

perseveration, and the Bernreuter scored for both neurotic tendency and

introversion-extraversion, they called objectivity. Factor II, indicated by

positive loadings with total number of responses on the Rorschach, speed,

and the Bernreuter scored for dominance and self-sufficiency, they called

fluency. They interpreted these as directional characteristics of function

which, theoretically, should manifest themselves in alertness to objective

stimulation. The greater the objectivity and the fluency, the greater the

personal stability. In the program indicated, their aims are to utilize

factor analysis in a systematic search for directional variables, and to

apply these to the abnormal, in order to permit objective measurement

of developing stability in youth and in therapy. 13

Deficit in Specific Aspects of Behavior

For both receptive processes and active processes the evidence of

deficit becomes more pronounced as performance becomes more complex.

This basic principle was pointed out long ago by Hughlings Jackson

(Head, 1926, p. 52) in connection with his investigations of aphasic

phenomena. It has been reiterated for other disorders by Wells (1919),

by Hollingworth (1930), by Conkey (1938), and by Goldstein (1938).

13 Moore (1930, 1933) has also used factor analysis on ratings of psychiatric

symptoms in an effort to arrive at empirical syndromes.

990 PERSONALITY AND THE BEHAVIOR DISORDERS [32

Conkey also noted that recovery occurs most rapidly in the more simple

types of performance.

Receptive Processes.

RECEPTOR THRESHOLDS. Where the patients need report only the

presence or absence of stimulation in some receptor, the majority of the

little evidence available shows no deficit. Franz (1910) found no evi-

dence of raised tactual thresholds in psychotics that could not be related

to momentary inattentiveness. Grabfield (1914) reported raised thresh-

olds to faradic shock in all diagnostic groups excepting psychoneurotics

(1917) and manics (1915a). In 51 schizophrenics the average threshold

was high, and about 40% were outside the normal range (1915b). But

when Huston (1934) repeated Grabfield's work on schizophrenics with

a better technique, he found no significant differences between the means,

the scatter about the means, or the interval between ascending and de-

scending series for his patients and his control subjects. Morel (1936)

found normal audiometer curves in 31 patients with auditory hallucina-

tions. The threshold was raised in occasional series of presentations

while the patient was apparently hallucinating, but it returned imme-

diately to normal. The thresholds of schizophrenics, reported by L. E.

Travis (1924) and R. C. Travis (1926) in their studies of the effects of

reverie on auditory and visual thresholds, averaged no higher than those

of their controls, although they showed more variability. Gelb and Gold-

stein (1920) reported visual acuity to be satisfactory in several cases of

brain injury exhibiting marked perceptual defects. On the other hand,

Baird (1906) reported contracted color zones in three of five neuras-

thenics, and Quensel (1931) reports work by Stern indicating that raised

thresholds may underlie defects in visual perception. Good sensory

studies are needed. With modern techniques they would be feasible.

PERCEIVING. In receptive processes where patterns of stimulation

must be organized and where learned sets or attitudes play a part, both

"functional" and "organic" patients frequently show marked deviations

from the normal. When she had schizophrenics copy the Wertheimer

figures, Bender (1938) found that they separated the parts, got some

parts disoriented in relation to others, and changed the orientation of the

figures on the page. Manics, when they cooperated, tended to elaborate

the designs without showing evidence of disturbance in these "basic

Gestalt principles." Greatly depressed patients occasionally showed the

patterns of disorganization found in the "organic" confusional states.

Those less depressed tended to draw with exceeding care and pre-

cision. Bender gives no data concerning the proportions of patients who

showed these disturbances. Kraiz (1936) has reported that some

schizophrenics see stationary objects as if they were moving away from

the eyes ; the visual field may become constricted or so disorganized that

the size, the spatial relations, and the consistency of objects are changed.

Several investigators have reported the perception of the body to be

altered in the "functional" psychoses (Kraiz, 1936; Schilder, 1935;

32] PSYCHOLOGICAL DEFICIT 991

Angyal, 1935). In a depersonalized schizophrenic who reported the floor

as waving, Angyal analyzed the phenomenon as an exteriorization of the

pulse in the plantar region. Cupcea (1936) has reported the absence of

the size-weight illusion in 30% of 129 psychotics.

Street (1934) found that both schizophrenics and manic-depressive

patients perceived partially drawn figures less readily than did normal

individuals. Hunt and Guilford (1933) and Cameron (1936) have found

that manic-depressive patients, particularly, see the fluctuations in an

ambiguous figure with great difficulty. Once the shift in perspective has

been seen, the rates of fluctuation reported are distinctly below those

reported by either schizophrenics or normal individuals whose rates are

approximately the same.

In an interesting study that should be extended, Malamud and Ny-

gard (1931) found that a few schizophrenic and psychoneurotic patients

reported a given distance on the skin as greater when subtended by two

points of pressure than when subtended by pain. This tendency reverses

that found for almost all normal individuals, and Malamud and Nygard

argued that the tendency among psychoneurotics particularly to repress

and to compensate for their unpleasant states is generalized to every sort

of activity. 14

Hallucinations constitute the most common form of perceptual symp-

tom in the "functional" psychoses. They appear in from 60% to 80% of

schizophrenics, and in about 35% of manic-depressive patients, but in

only about 20% of patients with "organic" psychoses. Auditory halluci-

nations are more prevalent than visual (Lind, 1915; Harrison, 1916;

Bowman and Raymond, 1931). Recently, Kliiver (1942) has organized

a large body of observations on hallucinatory phenomena. Hallucinations

apparently have a central origin. In psychoanalytic theory they are ex-

plained as wish-fulfillment or projections of the super-ego (Fenichel,

1934, p. 331 ff). Where the latter sort of psychoanalytic explanation is

applicable, hallucinations may also be considered as conditioned sensory

responses. Here perception of the initial stage of a previously punished

act should serve as the conditioned cue.

Cerebral damage may disturb pattern perception in several ways.

Some of the most informative studies are the intensive investigations of

individual cases grounded in Gestalt theory. Gelb and Goldstein (1920)

describe a case of occipital injury with normal acuity who could read

slowly and recognize most ordinary objects, but only when he followed

the outline with head or hand movements. When they prevented these

movements either by restricting devices or by shortening the exposure,

this patient could neither read nor recognize forms. He could not recog-

nize a cross-hatched word or objects drawn with discontinuous dots. He

could not describe the form of after-images or apprehend "seen move-

ment" such as the "phi" phenomenon. Similar but less pronounced de-

14 This argument is akin to that upon which the protective methods are based.

See Chapter 6 by White, and for the results of the Rorschach test, see Klopfer and

Kelley (1942),

992 PERSONALITY AND THE BEHAVIOR DISORDERS [32

fects of visual perception have appeared in a case of partial bilateral

frontal lobectomy. When Nichols and Hunt (1940) presented the first

plate of the Ishihara test of color blindness with the unspecific instruc-

tion: "What do you see here?" their patient answered: "A big round

spot of blue which is made up of small round blue dots, and some red

dots." He missed the "12" completely until later when he was asked

to report what figure he saw in this plate.

In the traumatic psychoses with confusional states, the perceptual dis-

turbances uncovered by having patients draw the Wertheimer figures

(Bender, 1938) appeared as a disintegration of the parts of the figure

from the background, and Goldstein (1937) has found a similar disturb-

ance also characteristic of Pick's disease. Acute alcoholics reproduced

the Wertheimer figures incompletely and disorted them with persever-

ative strokes. Paretics showed a number of different disturbances that

Bender related to clinical syndromes. Schilder (1934) has found that in

the acute confusions following head injuries points are extended as lines,

angles are changed to straight lines, orientation on the page is changed,

and connected parts of the figures are separated.

Harrower (1939) has found a rigidity of set manifested in the figure-

ground perception of 30 patients with cerebral lesions not involving the

occipital lobes. She presented Rubin's vase wherein the outlines of two

human faces appear nose to nose, three modifications of this figure in

which the vase was enhanced, and three modifications in which the pro-

files were enhanced. Four sorts of deviation from the behavior of her

control-group appeared : ( 1 ) marked perseveration of the set engendered

by the first perception; (2) failure to recognize any meaningful object

in the ambiguous figure even after correctly perceiving all the other fig-

ures; (3) such rigidity of set that the less dominant figure could not be

seen at will despite its having been seen in drawings where it was domi-

nant, and (4) seeing other objects than profiles or vases throughout the

series.

Slowing of pattern perception has been reported repeatedly in cases

with cerebral damage. 15 In acute confusions following head injuries,

Schilder (1934), for instance, demonstrated with tachistoscopic examina-

tion that it took from 200 ms. to 500 ms. for these patients to recognize

objects normally recognized in 40 ms. Gelb and Goldstein (1920)

showed that the slowing in their case of occipital injury was based on

the overt movements required for the recognition of objects, but such

an explanation cannot be generalized.

Although these few studies give no systematic picture of the receptive

processes in either the "functional" psychoses or the various "organic"

conditions, and the same patients have not served in both the threshold

and the perceptual studies, it appears tentatively that the perceptual proc-

esses show the greater evidence of deficit. Furthermore, the deficit

appears to reside in the central processes initiated by receptor action,

15 See: Poppelreuter (1917), Liljencrants (1920), Gelb and Goldstein (1920),

Schilder (1934).

32] PSYCHOLOGICAL DEFICIT 993

particularly in the response to patterns and in the alteration of sets or

attitudes.

Active Processes.

REACTION-TIME. Almost as soon as the early studies of the personal

equation had established the measurement of reaction-time in psy-

chological laboratories, the German investigator, Obersteiner (1874), re-

ported lengthened reaction-times in psychotic patients. Since then the

reaction-times of psychotics have been measured with various consider-

ations in view, e.g., to get diagnostic criteria, to get an index of chang-

ing clinical conditions, and to understand psychotic symptoms. 16 Most

of the earlier investigators used too few subjects to establish differences

among psychotic groups or between psychotic and normal groups. Al-

though their techniques and aims differ too much to allow specific com-

parison of statistical constants, certain tendencies have appeared so con-

sistently in their studies that they are undoubtedly reproducible.

All investigators agree that the average reaction-time for every diag-

nostic group is longer than that for groups of normal individuals.

Patients with "organic" disorders apparently react more slowly than

those with "functional" disorders (Bevan-Lewis, 1890; Diefendorf and

Dodge, 1908; Wells and Kelley, 1922), but this can hardly be considered

an established fact. The reaction-times of manic-depressive patients most

nearly approximate the normal. Franz (1906b) was originally surprised

to find manics slower than his normal subjects.

Individual differences are increased as would be expected from the

fact that some patients in every diagnostic group react as quickly as

normal subjects while others show considerable slowing. The slowness

of response has been found associated with clinically judged severity of

disorder in manic-depressive patients tested repeatedly (Franz, 1906b;

Lundholm, 1922), and with relative severity in different individuals

tested once (Diefendorf and Dodge, 1908; Scripture, 1916; Huston,

Shakow, and Riggs, 1937). Failure to find such association has also

been reported by Wells and Kelley (1922) and by Saunders and Isaacs

(1929).

Intra-individual variability, as measured by the standard deviation of

a series of reaction-times from a single subject, is increased in all the

diagnostic groups. 17 Whether manics or depressed patients show the

greater variability is still an unsettled question; Lundholm (1922) and

Wells and Kelley (1922) say manics, but Franz (1906b) and Bevan-

Lewis (1890) say depressed patients. Several investigators have re-

ported greater intra-individual variability in the "functional" disorders

than in the "organic" (Bevan-Lewis, 1890; Scripture, 1916; Wells and

16 Reviews of the applications of this method in the psychoses are available in

several papers: Franz (19065), Wells and Kelley (1922), J. McV. Hunt (1936),

and a comprehensive bibliography to 1929 in a paper by Saunders and Isaacs (1929).

17 See: Bevan-Lewis (1890), Franz (1906), Scripture (1916), Wells and Kelley

(1922), Saunders and Isaacs (1929), Huston, Shakow, and Riggs (1937), and

Rodnick and Shakow (1940).

994 PERSONALITY AND THE BEHAVIOR DISORDERS [32

Kelley, 1922), and so far as we know, no one has reported the contrary.

This finding, coupled with the discovery of a higher percentage of antici-

patory reactions among patients with "functional" disorders in an experi-

ment where the subjects were instructed to press a key the instant two

lines coincided (Saunders and Isaacs, 1929), suggests that the long

average reaction-times of patients in the "functional" group are more a

matter of motivation and attitude, while those of "organic" patients are

more a matter of slowed processes.

Partial substantiation of this hypothesis comes from studies in which

the reaction-time method has been used to show that schizophrenics have

difficulty sustaining the task or set to respond. Huston, Shakow, and

Riggs (1937) assumed that the slowness and variability of schizophrenics

might be due to failure to maintain a "high state of readiness to respond."

To test their hypothesis, they had their subjects respond to both lights

and sounds after preparatory intervals varying from .5 to 10 seconds.

In one part of the experiment, a series of reactions was measured with

each of the preparatory intervals so that the subject could become accus-

tomed to responding after each one. In another part, reaction-times

were measured with the preparatory intervals arranged randomly. Nor-

mal subjects averaged shorter times and were less variable with the

"regular" procedure, but for the longer preparatory intervals their aver-

ages increased and approached those of the "irregular" procedure.

Schizophrenic reaction-times for the "regular" procedure rose much

more sharply as the preparatory interval was prolonged, and reached

equality with those of the "irregular" procedure at somewhere between

2 and 3 seconds. For still longer preparatory intervals in the "regular"

procedure, schizophrenics had longer reaction-times than they did for

the "irregular" procedure. Patients judged "cooperative" performed

more nearly like the normal than did others. Rodnick and Shakow

(1940) have repeated this experiment with an extended range of pre-

paratory intervals (1 to 25 seconds). The former trends were thus exag-

gerated, and they were enabled to construct a composite "set index"

from their measures that discriminated between their schizophrenics and

controls without any overlapping, even though their control subjects

were selected for low intelligence and meager ambition. 18 This is the

only score known to us that has differentiated any diagnostic group from

a normal group without any overlapping. More important, however, than

its possible significance for diagnosis, is the fact that it demonstrates

clearly that schizophrenics do not sustain the preparation or task to

respond for as long a time as do normal subjects.

18 This composite index is expressed in terms of a single number. The formula

is as follows :

"Set index" = 1/2 + -' M. + . M,,

\M.7.5t Ml5i/ Mir

where : MK is the longest mean reaction-time for any series of 10 trials

r stands for "regular" procedure

i stands for "irregular" procedure

The numbers stand for the lengths of the preparatory intervals in seconds

3 2] PSYCHOLOGICAL DEFICIT 995

It is interesting theoretically to consider the results of these reaction-

time studies in relation to the so-called apathy of schizophrenics and to

the conception <of this disorder as "withdrawal from reality.'*' In work

on animal learning, the reaction-time or latency of a response is fre-

quently used as a measure of its strength (Graham and Gagne, 1940).

The shorter the latency, the stronger is the response. Frustrating the

satisfactions derived through a response consistently weakens the re-

sponse, i.e., increases its latency (extinction). Furthermore, an indi-

vidual animal's latencies show great variability during the course of ex-

tinction (Hunt and Solomon, 1943). Seen from this standpoint, the

slowness and the excessive variability of the reaction-times of schizo-

phrenics and their failure to maintain a set to react might be taken to

indicate a partial extinction of their responses to social stimuli. One

should remember in this connection that the response used in these

studies of reaction-time is motivated by an experimenter's instructions.

According to this interpretation, more complete uncooperativeness would

represent a more complete extinction of social responses in these patients.

Apathy would represent a more generalized extinction or weakening of

the interests learned in the course of social interaction. We would regard

these interests as acquired drives (see Miller and Dollard, 1941, Ch. 4).

Furthermore, the notion that extinction consists of substituting some

other response for the one extinguished would allow for the incorpora-

tion of the clinically discerned preoccupations characteristic of schizo-

phrenics into this interpretation, for instance, as substitute responses of

an implicit sort. The psychoanalytic notion that the schizophrenic's libido

is withdrawn from reality as a result of frustration, and redirected toward

internal processes or the ego (Fenichel, 1934; Symons, 1941), to us is

essentially similar to this hypothesis we have given. An immediate prob-

lem arising from this hypothesis is to determine whether the variability

of reaction-times and the "set indices" of "organic" patients differ from

those of schizophrenics. 10

LATENCY OF THE PATELLAR-TENDON REFLEX. Although weakened

preparation for response might account for lengthened reaction time in

the "functional" psychoses, the question of slowed neural conduction

itself has been raised. Franz (1909) measured the latent-periods of the

knee jerk in eight paretics. He found it slightly longer than normal, but

his technique was inadequate. More recently, L. E. Travis and his

collaborators 20 have measured the latency of the patellar reflex in cases

of "functional" psychosis with a view to testing the hypothesis of a re-

ciprocal relationship between higher and lower nerve centers. Con-

19 From the point of view expressed here, the term "functional" would mean

based on learning processes. This does not imply an absence of organic basis. But

if this interpretation of schizophrenic symptoms should be correct, the search for

their organic basis becomes but a part of the search for the organic basis of all

learning.

20 See: Travis (1928), Travis and Dorsey (1929), Travis and Young (1930),

Dorsey and Travis (1932), and Dysinger (1932).

996 PERSONALITY AND THE BEHAVIOR DISORDERS [32

sidering the catalepsy, muteness, stupor, and disorientation of catatonics

as evidence of hypo-function of the cortex, decreased latencies were

theoretically expected and found. Increased latencies were predicted and

found in manics. We shall not attempt to summarize these studies in

detail, for when Huston (1935), in a very careful study, measured

patellar latencies in 68 male schizophrenics and in a group of 53 normal

male adults matched with the schizophrenics for age, education, and the

like, significant differences between the groups in neither means nor

standard deviations of latency appeared. Huston, whose interest was

concerned directly with the possibility of slowed neural conduction as an

explanation of the slowness of schizophrenics in reaction-time and tap-

ping, concluded that this slowness of schizophrenics cannot be attributed

to neural defect unless this defect has a locus in centers higher than those

involved in the patellar reflex-arc.

DEFICIT AND COMPLEXITY OF THE REACTION. It is interesting to

relate the size of the differences in reaction-time found for schizophrenics

and controls to the complexity of the task involved. Fortunately for this

purpose, the work at Worcester State Hospital was all done on the same

basic population of schizophrenics and controls, although the samples in

the various experiments were not coextensive. In Figure 1, by con-

sidering the origin on the ordinate as the average time for normal re-

action, the bars represent the differences in milliseconds between the

mean times of schizophrenics and controls for reactivity of three levels

of complexity. For reflex-time (Huston, 1935), the simplest level, the

means for the two groups are essentially identical. For simple reaction-

time (Huston, Shakow, and Riggs, 1937), the differences between the

groups are fairly marked and are statistically significant. Although visual

times are considerably longer than auditory, the differences between the

groups are similar, 190 ms. and 197 ms. respectively, indicating that

when complexity of task is held constant the difference between the

groups is relatively constant. For the simplest of choice reactions in-

volving a simple visual discrimination (Huston, Shakow, and Riggs,

1937) another marked increment in the difference between the groups

appears. The reactions of patients have been found to average much

slower than normal for still more complicated activities : for various types

of choice-reaction (Wells and Surges, 1918; Mailloux and Newburger,

1941), for word associations (Otis, 1913; Strong, 1913; Wells, 1919a),

for reactions on a substitution-test (Wells and Currie, 1923), for many of

the standard tests (Babcock, 1930 and 1941). Unfortunately, however,

the data for these tasks at still higher levels of complexity are not com-

parable with those in the Worcester studies. If, on the basis of this

other evidence of slowing, we extrapolate the tendency in Figure 1, we

have quantitative evidence that the deficit becomes greater as the com-

plexity of the task increases. Evidence necessary to relate this tendency

to the various types of disorder is still lacking. We must agree with

Babcock's (1941) emphasis on the importance of time in behavioral proc-

PSYCHOLOGICAL DEFICIT

997

esses to the extent that measures of the time required for various types

and complexities of performance should prove a ready quantitative

approach to certain aspects of deficit and also of intelligence.

[300

reflex- aud vis vis

time simple reaction-time discrimination-time

complexity of task

Figure 1

As the complexity of the performance increases, the slowness of schizophrenics,

which is absent at the level of the patellar reflex, becomes progressively more

marked. The origin on the ordinate represents the average time for normal reaction,

and the bars represent the differences in milliseconds between average normal and

average schizophrenic reactions. (From data in papers by Huston, 1935, and

Huston, Shako w, and Riggs, 1937.)

PATELLAR REFLEX. Changes in the strength of the patellar reflex

in the various organic disorders have been recognized and utilized for

diagnostic purposes for a long time. In one of the early studies of

patellar phenomena, Franz (1909) analyzed the records of 4,199 cases

of paresis and found exaggerated reflexes in 47%, normal reflexes in

24.6%, and reflexes diminished or absent in 21.8%. Diminished reflexes

were associated with fixed pupils, but not with any "mental" phenomena

accessible to Franz. In an investigation of the patellar reflex in the

"functional" psychoses, Strecker and Hughes (1936) found that increas-

ing the stimulating blow brought similar Increments of reflex-tension

in schizophrenics and normal subjects, excessive increments of tension

in depressed patients, and no increments in tension in manics and in

agitated involutional patients. When they measured the reinforcing effect

of stretching a spring scale between the hands with 4 kg. of force on

maximally stimulated responses, schizophrenic responses were again like

the normal, but depressed patients showed no reinforcement at all, and

manics showed a typically small and varied amount from moment to

moment. Viewing these results in the light of Sherringtonian theory,

they argue that in depression there must be a great many impulses com-

ing down the cord. These so increase the excitability of the anterior horn

cells that a powerful blow will fire all motor neurones available to the

patellar reflex and leave none to mediate reinforcement. This is an in-

998 PERSONALITY AND THE BEHAVIOR DISORDERS [32

teresting lead. Moreover, it is unusual to find manic-depressive patients

differing more than schizophrenics from the normal in any performance,

OCULAR MOVEMENTS. Years ago Diefendorf and Dodge (1908)

found some interesting anomalies in ocular movements recorded on

photographic film with a mirror recorder actuated by the corneal pro-

tuberance. Particularly inadequate were the pursuit reactions of paretics.

Instead of following the object in smooth movement, most paretics and

some schizophrenics showed a variety of jerky interruptions. Later

Dodge and Fox (1928) revived the method. From a series of studies,

the last by Couch and Fox (1934), it appears that in about 50% of

psychotic patients the records of eye-movements are normal except for

deviations resulting from "lapses of attention." Normal ocular responses

may occur in very sick patients. The step-like interruptions of pursuit

movements appeared in the records of approximately one-third of the

patients, but they were characteristic of no diagnostic group.

RATE OF MOVEMENT IN TAPPING. The tapping test has been used

to investigate the efficiency of psychotic patients ever since Kraepelin

(1896) introduced it. The average rate of tapping is probably reduced

in all psychotic groups. Of the "functional" disorders, for which the

available data are best, schizophrenics average slowest (mean: 19.5 taps

in 5 seconds), manic-depressive patients next (24.8), and the controls

averaged 28.9 taps. Group differences were all statistically significant

(Shakow and Huston, 1936). Investigators have been surprised to dis-

cover that this slowing of such performance apparently applies to hyper-

active manics as well as to other kinds of psychotics (Franz, 1906).

CONTINUOUS WORK. Kraepelin (see review, 1925) originally intro-

duced the technique of continuous work because tasks involving but short

intervals of performance failed to bring out the deficit evident in every-

day life. With various types of tasks schizophrenics work efficiently for

a brief period, but performance falls off at an abnormally high rate as they

continue. On this kind of observation Kraepelin (1919) appears to have

based his judgment that dementia praecox manifests itself largely as a

disturbance of volition. 21

An outstanding exception to this tendency toward rapid reduction

of efficiency with continuous performance appears in manic-depressive

patients. Using the ergograph, Hoch (1901) found that depressed pa-

tients increased the strength of their pulls during a single exhaustion

curve before the reduction that comes with exhaustion appeared. More-

over, these patients increased the number of lifts with successive exhaus-

tion curves. This reversal of the fatigue-effect in depressed patients has

also been shown for the rate of tapping (Wells, 1919; Strong, 1913), for

performance on a substitution test (Wells and Currie, 1923) and on an

31 Incidentally, it is worth noting that weak volition is probably operationally

synonymous with weak drive or low motivation. Moreover, all of these terms have

much in common with "withdrawal from reality."

3 2] PSYCHOLOGICAL DEFICIT 999

addition test (Hull, 1920). Although most investigators have considered

this reversal characteristic only of the depressed and retarded and con-

sidered it evidence of generalized inhibition (Hoch, 1901; Franz and

Hamilton, 1905), Strong (1913) found it more universally among

manics than among the depressed. In an unpublished study, Hunt has

found similar effects operating with performance on graded arithmetic

progressions, and they were just as evident in manics as in depressed

patients. Whatever its explanation, here is a clearly reproducible phe-

nomenon, manifesting itself in various sorts of performance, that occurs

only in the manic-depressive. No data on the prevalence of the phe-

nomena in manic-depressives are available.

Association. Since Gal ton (1879) first described the process of free-

association and suggested its use for "uncovering the uncharted depths

of the mind/' in various modifications it has become one of the most

prominent tools for the study of personality and disorder. Of the four

chief modifications, three have been fruitful.

The least fruitul of these modifications is the classification of verbal

responses according to their logical relation to a given list of stimulus-

words. This method was brought from Wundt's laboratory by Aschaffen-

burg (1895, 1899, 1904). Later, Murphy (1920, 1922) continued this

approach in America, but he concluded it was fruitless, and agreed with

Kraepelin (1919) who had written that "the association-experiment

strikes chiefly at the crystallization of the habits of speech, which are for

the most part little influenced by the disorders/* 22 As Kent and Rosanoff

(1910) have pointed out, however, whatever the condition of speech

habits in patients, the process of logical grouping is unlikely to uncover

anything significant about them, for the significant connections con-

cerned are psychological rather than logical.

Most famous of the fruitful varieties of associative method is Freud's

(1914) continuous free-association, which he appears to have hit upon

independently. He developed it as the methodological keystone of psycho-

analysis. The fact that the associations of a subject lead backward

biographically makes of this method an inverse approach to learning

that has taken place within an individual's life history (see Chapter 7

by French). Continuous free-association, however, has been used as an

approach to etiology rather than to deficit.

A second of the fruitful varieties is Jung's (1906) adaptation of the

22 Although the results from vocabulary and information-tests appear to be in

line with this view, evidence from the little known study of McDonald (1915)

argues that the grammatical structure of speech is considerably altered in the

psychoses. He recorded 500 consecutive words from the spontaneous speech of

manic-depressive, schizophrenic, and paretic patients, tabulated the parts of speech,

and compared these with similar tabulations from the writing of normal adults and

children. No patient used as many different words as the child with the poorest

vocabulary. Reduced were the proportions of nouns and articles, and increased

were the proportions of verbs, pronouns, and adverbs. The patients used a larger

proportion of adjectives than did children, but less than did adults. Some differences

were also apparent among these diagnostic groups.

iooo PERSONALITY AND THE BEHAVIOR DISORDERS [32

method of discrete associations to single stimulus words for psycho-

pathological experimentation. From such indicators as delay or blocking

of association, repetition of the stimulus word, blushing or embarrass-

ment, and from galvanic reactions and disturbances of breathing corre-

lated with these indicators (Peterson and Jung, 1906), he appears to

have inferred the "complex" as a "system of emotionally toned ideas."

In this work Jung was attempting to test Freud's generalizations experi-

mentally. He considered his results confirmatory. He found evidence of

more complexes in neurotics and psychotics than in normal individuals.

Work with word-association was important in leading Jung to his con-

ception of dementia praecox (1909) and to his (1923) division of men

into introverts and extraverts and their admixtures. Introverts were

individuals who gave associations characterized by subjective or egoistic

reference (e.g., table: eating, study, sleep, elegant). Extraverts, on the

other hand, gave associations characterized essentially by objective con-

tiguity in space and time (e.g., table: chair, lamp, plate, cover). Because

the great majority of the associations of manics were objective, this dis-

order was considered the extreme of extraversion. Little, we believe,

has ever been added to or subtracted from the findings Jung got with

his method. 23

The third fruitful modification of the association-method is that of

Kent and Rosanoff (1910). They got the responses of 1,000 normal

subjects to a stimulus-list of 100 words, and tabulated them in a fre-

quency table. 24 This standard list enabled them, first, to classify the asso-

ciations to the stimulus-list from any new subject as "common" (present

among the 1,000 responses to this word) or as "individual" (not

present), and secondly, to score the degree of commonality of each

response in terms of the percentage of the 1,000 subjects who originally

gave that response to the stimulus-word concerned. When they gave

their stimulus-list to 247 psychotics, the group as a whole gave a higher

than average percentage of "individual" responses (26.8%) than did a

control group (6.8%). Moreover, schizophrenics gave the highest pro-

23 It seems to us that the methodological kernel of Jung's work has been gen-

erally missed. His point that schizophrenics and manics represent the extremes of

introversion and extraversion and his recourse to an admixture of intermediate

types both imply a measurable variable. This appears to have been the proportion

of associations with subjective and with objective reference (see Jung's studies in

word-association, 1919). With clinical observation Jung appears to have correlated

the relative extremes of such proportions with personal traits. Untrained statistically,

he described the trait-correlates of these associative tendencies without their statis-

tical limitations, and cast his findings and his speculations into the mould of a

typology. His emphasis on the trait-correlates obscured the essentials of his method.

Americans with statistical sophistication, but with probably less psychological

sophistication than Jung had, have attacked his problem with questionnaires and

ratings for the clinically observed correlates of the basic variable. This mass of

American work (for bibliography see Guilford, 1934) has largely by -passed Jung's

basic problem. His work should be repeated with a statistical approach.

24 Copies of this standard list as reprinted from RosanofFs psychiatry (1938)

are available from John Wiley & Co. In view of the changes in our culture which

have occurred during the last 30 years, the standardization should probably be

repeated.

32] PSYCHOLOGICAL DEFICIT 1001

portion of "individual" responses (38.5%), manic-depressives were sec-

ond with 21.5%, and approximately 20% appeared for all other types of

disorder. Repetitions of this work with schizophrenics (Wells, 1919a ;

Rawlings, 1921) and with manic-depressives (Wells, 1919a: Strong,

1913) have yielded average percentages of "individual" responses closely

approximating those of Kent and Rosanoff. Tendler (1933) found the

percentage of "individual" responses for psychoneurotics closer to the

normal than to the psychotic average. He found a subgroup, however,

whose responses resembled those of children. Wells (1919a) found the

percentage of "individual" responses especially high in "deteriorated"

schizophrenics, and in manic-depressive patients it reduced as their clini-

cal condition improved.

Although most investigators have disparaged the Kent and Rosanoff

method as a diagnostic device because the distributions of "individual"

percentages for normal and psychotic groups overlap, the fact that these

percentages are exceptionally high in schizophrenia has considerable

theoretical interest. If it can be assumed that these verbal associations

represent habits inculcated in social interaction, one would expect these

high "individual" percentages from the psychoanalytic view that schizo-

phrenia represents a withdrawal from social reality. Moreover, one

should not expect them from brain injury not involving the speech areas.

Further work with this method is desirable to test this hypothesis.

Emotional Behavior. A majority of the investigations of emotional

behavior in the disorders have been concerned with testing the notion

that schizophrenics are apathetic. We shall survey this material from this

standpoint, and proceed from simple, basic processes to those more com-

plicated and modifiable.

The startle pattern is a universal and comparatively stable response

consisting of blinking the eyes, stereotyped facial movements, head move-

ments, hunching the shoulders, abduction of the upper arms, bending of

the elbows, pronation of the lower arms, flexion of the fingers, forward

movement of the trunk, contraction of the abdomen, and bending the

knees (Landis and Hunt, 1939). When the startle reaction to a pistol

shot is recorded by high-speed cinema, it can be analyzed and quantified.

With such a technique, Landis, Hunt, and Page (1937) repeated

Strauss's (1929) early observations with normal speed photography

and found the startle response intensified in schizophrenics, particularly

in patients of the catatonic subgroup, and somewhat intensified in the

manic-depressive and involutional groups. Paretics and encephalitics re-

sponded normally. The response was reduced in epileptics, but the

degree of reduction appeared unrelated to any known clinical variables.

From the standpoint of the James-Lange theory, wherein emotions

are conceived as the perceptions of the bodily changes aroused by changes

in the situation, it has been considered that schizophrenics should exhibit

reduced visceral reactions to such exciting stimuli as noises, electrical

shocks, and painful pressures. So far as average quantity of reaction is

1002 PERSONALITY AND THE BEHAVIOR DISORDERS [32

concerned, however, the bulk of results fails to confirm this prediction.

Schizophrenics have given breathing changes, measured with the pneumo-

graph, about equal to those of normal subjects. 25 Their changes in blood

pressure, as measured by the plethysmograph (DeBruyn, 1909) and the

manometer (Gordon, 1930), are about equal to those of the normal.

Schizophrenics' changes in pulse-rate following painful stimulations are

as great as the normal (Coriat, 1910) or even greater (Cohen and

Patterson, 1937). The latter investigators found that increments in

heart-rate following painful pressures either increased or failed to de-

crease with serial presentation in schizophrenics, while they decreased

considerably in normal subjects. Results from the galvanic skin-response

are inconsistent (see Landis, 1932), but in later studies, schizophrenics'

responses averaging as great as the normal have been reported (see

Hunt, 1936a).

On the other hand, the expressive records of schizophrenics have

shown greater intra-mclividual variability than is normal (see review by

Freeman, 1933). For instance, Forbes and Piotrowski (1934) found

greater minute-to-minute variability in the resistance of the skin to small

electric flow in 10 catatonics than in the normal, and Richter (1926) has

found schizophrenics more variable than any of the "organic" groups on

these indicators of autonomic activity. Thus, it appears that variability

rather than reduction characterizes the expressive emotional behavior of

schizophrenics.

Evidence that "felt emotion" need not disappear in schizophrenia

comes from the reports of patients. Lang (1939) writes that "the actual

loss of affective strength is considerably less than it seems. For me, ex-

ternal stimuli still retain considerable affective potential even after 9.5

years of the psychosis" (p. 196). On the other hand, we have also

heard schizophrenics complain that they "don't feel anything anymore/

Whether this felt apathy concerns only particular interests or is truly

general is uncertain. Olson (1931) failed to find anything significantly

different from the normal on the Pressey X-0 test where the subject is

to cross out unpleasant words, but Wechsler (1939) did find that schizo-

phrenics expressed an interest in more occupations after insulin-therapy.

All one can say is that subjective apathy is not universal among schizo-

phrenics.

Although no reduction of emotional behavior at the reflex or au-

tonomic level appears in schizophrenics, they show marked deviations

from the normal and probably from the behavior of patients with "or-

ganic" disorder in overt behavior related to emotion. Instead of jerking

their hands away quickly, Bender and Schilder (1930) found that

stuporous catatonics usually responded to painful electric shocks with

tonic squirming in the stimulated hand, tenseness of the whole body, and

the visceral reactions mentioned above. Such squirmings were easily

25 See: DeBruyn (1909); Pollock and Dollear (1916); Bender and Schilder

(1930).

32] PSYCHOLOGICAL DEFICIT 1003

conditioned to light or touch signals, and furthermore, they generalized

to a wider range of conditioned stimuli than did the withdrawals of

normal subjects. This squirming response might argue for apathy as

Bender and Schilder thought, or it might argue that some other response

tendency interfered with hand-withdrawal. Generalization to an exces-

sively broad range of stimuli might argue for "incomplete analysis of

the situation" (Bender and Schilder), for a stronger conditioned re-

sponse, or for a higher degree of "sensitization" in the schizophrenic

than in the normal.

From another type of attack at the overt level comes evidence clearly

confirming the judgment of apathy in schizophrenia. In a study of the

"level of aspiration" with dart-throwing, Hatismann (1933) found that

schizophrenics, excepting the paranoid type, indiscriminately raised their

"bids" after failure or lowered them after success. The paranoid patients

clung to high "bids" regardless of objective scores and in spite of the

fact that they were doubly penalized for falling below their predicted

scores. This differs markedly from the behavior of manic-depressive

patients in this sort of situation. Escalona (1941) found the initial

"level of aspiration," measured in terms of predicted scores on a maze-

task and a pegboard, highest for manics, next for normal subjects, and

lowest for depressed patients. After failure, the order consistently

changed to normal subjects highest, depressed patients next, with manics

decidedly lowest. Manics either avoided seeing failure or were absurdly

afraid of it, while neither success nor failure in the situation affected the

initially low predictions of the depressed patients. Stumbar (1934) found

that schizophrenics failed to recall more "uncompleted" than "com-

pleted" tasks as did Zeigarnik's normal subjects. And Rickers-Ovsian-

kina (1937b) found that schizophrenics failed to show the normal adult

tendency to resume "uncompleted" rather than "completed" tasks. When

she (1937a) observed one at a time through a one-way screen the

behavior of matched groups of schizophrenics and normal subjects

toward a table laden with games and puzzles, no differences between

the groups in duration and consistency of response appeared. But the

normal subjects consistently played the games and attempted to solve

the puzzles, while the schizophrenics, excepting the paranoid patients,

aimlessly touched one object after another. Even during this aimless

manipulation, they appeared to be thinking about something else. She

concluded that "the dynamic conditions prevailing in peripheral regions

of the schizophrenic personality are such as to impede the formation of

the firm, segregated tension-systems necessary for directed activities"

(1937a, p. 176).

Here again the evidence of deficit becomes most pronounced in the

more complex and modifiable of the emotional processes. Apparently

the apathy of schizophrenics is expressed only at the overt level as lack

of interest in the surroundings and activities which typically concern

people. Here is evidence that the apathy of schizophrenics consists essen-

tially in a loss of socially acquired drives. Furthermore, this evidence fits

ioo4 PERSONALITY AND THE BEHAVIOR DISORDERS [32

our interpretation of schizophrenic symptoms as extinctions of socially

learned responses (see above),

IMPROVEMENT WITH REPETITION, INDIVIDUAL VARIABILITY, AND

THE QUESTION OF SCHIZOPHRENIC DETERIORATION. If deterioration is

defined as deficit increasing with time (Kraepelin's definition, 1915), the

generalization that schizophrenics deteriorate would require (1) that

they should show less output with successive repetitions spaced over a

relatively prolonged period, and/or (2) that the amount of improvement

effected by repetition should be less as the age of the psychosis increases.

Although schizophrenics have consistently shown less increase in output

with repetition of a performance than is normal, the fact that they do

generally increase their output on all sorts of tasks denies the first alter-

native implication. 20 Of particular significance in this connection is the

improvement between sessions, separated by intervals of three months,

that Huston (1932) found in performance on Miles' pursuitmeter and

that Shakow and Huston (1936) found in the rate of tapping. While

normal subjects showed improvement within each session, their scores

were poorer on the first trials of a new session than on the last trials

of a preceding session. Schizophrenics, on the other hand, improved less

within each session, but they actually averaged better for the first trials

of a new session than they had on the last trials of preceding sessions.

Shakow and Huston considered that this was a manifestation of a slow

adjustment of schizophrenics to the general aspects of the experimental

situation. The fact that Kendig and Richmond (1940) found a large

proportion of schizophrenics improve or maintain their level of perform-

ance in retests with the Stanford-Binet after several years of psychosis

also argues against this first implication of the generalization that schizo-

phrenics deteriorate.

The evidence available also contradicts the second implication. Kent

(1911) actually obtained the greatest improvement in repeated perform-

ances from the dilapidated schizophrenics who had been hospitalized for

years. The fact that the majority of single measures of output have failed

to correlate with the length of time that patients have been hospitalized

also argues indirectly against progressing deficit in schizophrenia. Thus,

the results of experiments aimed most directly at the crux of the ques-

tion of schizophrenic deterioration clearly contradict Kraepelin's general-

ization. It should be noted that many recent psychiatric observations

also contradict this generalization (see also Chapter 29 by Cameron).

These same studies have also shown consistently that the output of

schizophrenics on tasks repeated is much more variable than is the out-

put of normal subjects. Hunt (1936b) and Wittman (1937) have se-

cured evidence that intra-individual variability in output is greater in

schizophrenia than it is in such an "organic" psychosis as paresis. It

26 Both of these facts have been shown in all the studies of repeated performance.

See: Gatewood (1909), Kent (1911, 1918), Boring (1913), Huston (1932), Hunt

(1936b), and Shakow and Huston (1936).

32] PSYCHOLOGICAL DEFICIT 1005

has also been shown that the ups and downs of output in individual

patients is associated with similar ups and downs in psychiatric ratings

of "attitude" (Wittman, 1937) and in self-reported attitudes toward the

tasks of card-sorting and adding (Hunt, 1936b). Furthermore, Kent

(1918) and Hunt (unpublished study) have found that if one takes the

effort to gain the confidence and cooperation of schizophrenic patients,

one can frequently get large increases in output without what can be

considered practice. So far, Hunt has been unable to find any patient

with a typical "organic" disorder in whom such a cultivation of co-

operation automatically produces marked improvement in output. The

training given a case of bilateral frontal lobectomy was effective in in-

creasing output (Nichols and Hunt, 1940), but this consisted of teaching

concrete procedures, while getting cooperation consists in giving the

patient an impression that he is "understood" and appreciated. 27

Indirect evidence indicates further that the ups and downs in attitude

and in output shown by schizophrenics are associated with the variations

in emotional activity at the autonomic level. Gordon (1930) has found

variations in blood pressure associated with "distinct modifications of

the schizophrenic's attitude, behavior, and his mode of feeling and think-

ing." And still more indirectly, Sleeper and Jellinek (1936) found the

degree of polyuria in schizophrenics correlated significantly only with

judged emotional deterioration (negatively) and with IQ (positively).

Apparently the excessive water-drinking of these patients was emo-

tionally driven, and so long as the drive remains, they continue to mani-

fest interests and to perform relatively well on tests.

These findings argue that the deficit in schizophrenics is not progres-

sive, and also, that it is one of motivation rather than one of capacity.

Furthermore, the excessive variability of schizophrenic output, and the

relation of this output to reportable attitude and to cooperativeness con-

stitute more facts which fit our hypothesis that schizophrenic symptoms

represent the extinction of socially acquired drives and responses. 28

Conditioning. Perhaps the fact that a majority of the few studies

of conditioning in patients with "functional" psychoses show them equal

or superior to normal individuals is significant in connection with this

motivational interpretation of schizophrenic deficit. Pfaffmann and Schlos-

berg (1935) found that both manic-depressive and schizophrenic patients

averaged more conditioned knee jerks than did college students. Grecker

27 Hunt found this possible with only 17 of the 25 schizophrenics in his group.

One frequently observes, however, that given schizophrenics will cooperate for one

of a staff but not for others. Presumably if one could extend one's range of social

manners, one could increase the proportion of schizophrenics whose cooperation one

could obtain. It would be interesting to know how large the non-responding pro-

portion is.

28 These findings would also appear to confirm Kraepelin's (1919) contention

that "will" and "attention" are the aspects of "mind" that suffer most in dementia

praecox. It is interesting to note in this connection that these faculties are synony-

mous with "motivation" so far as any operational basis, of which we can think

or imagine, is concerned,

ioo6 PERSONALITY AND THE BEHAVIOR DISORDERS [32

(Razran, 1934) found no difference in the rates of acquiring a condi-

tioned tactual response by catatonic and normal subjects. Bender and

Schilder (1930) found that schizophrenics showed evidence of con-

ditioning quite as quickly as did normal subjects, but the conditioned

responses differed considerably. With a test based on conditioning and

extinguishing a response to avoid shock, Gantt (1938) found a high

degree of resistance to conditioning in several "organic" disorders. Al-

though he reports no specific results from patients with "functional"

disorders, Gantt implies that they may show less resistance by suggest-

ing that the test might be used to distinguish between the "functional"

and "organic" disorders. On the other hand, Shipley (1934) found that

schizophrenics both acquired and extinguished conditioned-galvanic-skin-

responses more slowly than any of his other groups, which in descending

order were : manic-depressives, psychoneurotics, and college students.

Studies comparing the ease of conditioning various kinds of responses

for a cross section of the hospital population would be very valuable.

Memory. Clinical observers noted long ago that senile patients

failed to recall or to utilize recent experiences even when older ones

could be recalled. Psychiatric literature describes this retrograde amnesia

as common also in general paralysis, psychoses with arteriosclerosis, and

Korsakoff's syndrome, but such a deficit is not considered characteristic

in the "functional" disorders. Several experimental investigations cor-

roborate these clinical observations. Simmins (1933) has shown that,

of the types of patients in her group, only patients with the senile psy-

choses, general paralysis, and epilepsy performed below normal on her

memory tests when general ability (#) was partialed out. Landis and

Rechetnick (1934) found good performance on tests of recent memory

more closely associated with clinical judgments of improvement in pare-

tics treated with pyrexia or malaria than any other type of performance.

When Wells and Martin (1923) gave to 111 patients their memory-test,

which involves eight types of impression varying in age from such

personal information as birthday and questions concerning standardized

school knowledge to recognizing twelve just previously presented post-

cards in a group of 24, the average of the senile group fell to the 53rd

percentile of the normal group and the average of the paretics to the

68th percentile, while that of manic-depressives fell only to the 74th, and

that of the schizophrenics only to the 82nd percentile. Even the gross

scores show the "organic" groups below the "functional" groups without

taking into account the general level of performance. Normal scores on

this test correlated -f--81 with intelligence.

On the other hand, Rawlings (1921), Foster (1920), and Babcock

(1933) have reported test-evidence for memorial defect in the functional

disorders. Rawlings even went so far as to consider her findings as

indirect evidence of cortical degeneration in schizophrenia. None of these

investigators partialed out the general level of performance, however;

and none found any memorial deficit as great in the "functional" dis-

32] PSYCHOLOGICAL DEFICIT 1007

orders as in the "organic." Beble's (1925) finding that the average

scores of post-encephalitics on Wells' memory test are insignificantly

below the normal indicates that cerebral damage need not affect memory.

No one, so far as we know, has found any memorial deficit except

temporary amnesia in patients following surgical injury to the brain.

The effects of age on memorial function have been shown in a recent

study by Shakow, Doekart, and Goldman (1942). When they plotted

the scores of 500 normal individuals, aged 15 to 90 and selected to pro-

vide a representative sample of the population at each decade, on Wells*

memory-test as a function of age, they found evidence of deficit to be

drastic after 60 years. Recent material was most affected. When the

scores of the various psychotic groups were compared with those of

normal individuals in the same decade of age, the effect of the psychoses

appeared much less than had previously been supposed. Patients with

senile psychoses showed more loss than did psychotics with cerebral

arteriosclerosis. In this latter group, vocabulary showed a relatively

greater loss than memorial functions, and scores on organized verbal

material were much more severely affected than those on such tests as the

repetition of digits. As these authors point out, such results raise the

question of generalized aphasia in these psychoses with cerebral arterio-

sclerosis. Moreover, aging appears to have more drastic effects on

memory as assessed by Wells' test than do even the "organic" psychoses.

Several investigators 29 have inquired whether the various psychoses

affect memory differentially according as its efficiency is tested by the

method of recall or the method of recognition. The significance of these

studies is unclear to us. Discrepancies between the results of the two

methods appear in individual cases, but they are not consistent for any

diagnostic group, and as yet they stand unrelated to anything else.

RETENTION AND IMPRESSION. Several studies tend to show that the

memorial deficit in the psychoses consists more of failure to effect an

impression than of failure to retain impressions. Of the various tests of

memory, those of immediate memory show the greatest loss, especially

in the "organic" disorders. Hull (1917, 1920) had patients associate

nonsense syllables with twelve Chinese characters to a criterion of one

perfect repetition. Patients required longer (av. 102 minutes) than the

controls (av. 26 minutes) to reach the criterion. Paretics required con-

siderably more time than did schizophrenics. Retention, measured in

terms of proportion of syllables recalled when the Chinese characters

were presented a week later, however, was better for the patients than for

the controls. But retention measured by the method of savings again

showed the controls superior. They could relearn to criterion more

rapidly than the patients. Wechsler (1917), using memory tests, also

concluded that memorial deficit, at least in Korsakoff's syndrome, con-

sists in an inability at the "fixation stage of memory."

29 See: Achilles (1920), Liljencrants (1922), Moore (1919), and Wylie (1930).

ioo8 PERSONALITY AND THE BEHAVIOR DISORDERS [32

Not all results have agreed with these. When Foster (1920) had

schizophrenics draw geometric figures repeatedly from memory, they

often elaborated them until they were unrecognizable. When Curran and

Schilder (1937) had subjects repeat a narrative over and over, they

did it willingly until the "trace appeared organized/' then further repeti-

tion produced a gradual deterioration of the pattern in both normal indi-

viduals and patients. A schizophrenic showed especially marked modi-

fications ; by the third repetition, no items of the original narrative per-

sisted. The characteristic failure of schizophrenics to sustain a task

would account for these results, however, and the fact that schizophrenics

have reported events, occurring while they were stuporous, with consid-

erable accuracy after the stupor argues that their failures of either

impression or retention may be an artifact of their uncooperativeness

(Lundholm, 1932). When Bender, Curran, and Schilder (1938) had

patients with KorsakofFs syndrome draw the Wertheimer figures re-

peatedly from memory, the tendency toward more primitive types of

organization became progressively more pronounced. Gantt (1938)

found that two cases of Korsakoff's syndrome retained a conditioned

defense reaction but a few minutes, while other patients with "functional"

disorders retained the same conditioned response for weeks. When he

had senile patients copy one of a pair of figures and draw another from

memory, D. E. Cameron (1940) found perseverative tendencies interfer-

ing with the process of impression, and compensatory tendencies to

elaborate interfered with retention. These results are interesting, but

generalizations are impossible at this stage. Deficiencies of impression

can hardly account for all memorial defects, however, for every clinical

observer has seen cases of paresis and senility who show progressive

retrograde loss of memory for the events of their lives. It would appear

as if such deteriorative processes damaged the structure carrying the

traces of previous behavior.

Language and Thought. Although disturbances of language and

thought have been evident for centuries (Jelliffe, 1930), most experi-

mental studies of them have appeared since the First World War.

APHASIA. (See also Chapter 18 by Cobb.) Interest in the language

disturbances of the aphasias started as a problem in cerebral localization

when Gall described the loss of speech with right hemiplegias in 1819.

(For the history see Head, 1926, and Weisenburg and McBride, 1935.)

Broca further stimulated this interest during the 1860's when he de-

scribed cases of speech disorder as a result of destruction of the triangular

and opercular portions of the inferior frontal gyrus of the left hemis-

phere demonstrated at necropsy. Trousseau introduced the term "aphasia"

in 1864. At about this same time Hughlings Jackson began his now

famous observations emphasizing the necessity for an empirical exami-

nation of the phenomena of speech-disturbances. 30 He conceived the

30 These papers received little attention until Head had them reprinted (see

Jackson 1915),

32] PSYCHOLOGICAL DEFICIT 1009

aphasias as disturbances of the power to "propositionise" which included

"internal speech" or thought and voluntary action as well as spoken or

written language. He agreed that the posterior portion of the left frontal

convolution is most frequently damaged in persons manifesting these

disturbances, but he argued that it was absurd to say that the destroyed

tissue "caused" the abnormal utterances. ". . . It has enough to answer

for in leaving him unable to speak . . . The positive symptoms arise

during the activity of lower centers or lower nervous arrangements

which have escaped injury" (Jackson, 1915, pp. 154-155).

The present status of the aphasias may be found in the works of six

investigators. The view that the aphasias consist in a list of specific

defects of language function, each based on lesions with specific locus in

the cerebrum, appears in the writings of Henschen (1921-22) and Kleist

(191418). On the sensory side, Kleist, for instance, differentiates word-

sound-deafness, word-deafness, name-deafness, and sentence-deafness ; on

the motor side, he differentiates speech-soimd-muteness, word-muteness,

name-muteness, and sentence-muteness. Each of these special defects is

conceived as the result of finely delimited lesions. Henschen believes that

even logical thought can be localized. Weisenberg and McBricle (1935)

point out that Kleist's work suffers because the examinations described

were not sufficient to show the actual characteristics of the changes in

language and behavior, and further, because the lesions in the brains of

his injured soldiers were not so precisely delimited as to justify the

conclusion of such nice relations between lesions and behavioral dis-

turbances.

In his famous work on aphasia, Head (1926) carried on the trends

initiated by Hughlings Jackson. He assembled a battery of serial tests

with standardized procedures which is excellent for analysis of the

various aspects of language behavior, but does not sample nonlanguage

behavior. From the empirical results of his work, Head concluded that

the aphasias were not specific defects of speaking, reading, and writing,

nor could they be classified as motor or sensory. He agreed with Jack-

son that they are disorders of "propositionising" for which he substi-

tuted the terms, "symbolic formulation and expression." The more ab-

stract the symbol, the greater the difficulty presented in aphasic patients.

Head's purposely loose classification of verbal, syntactical, nominal, and

semantic disturbances, which, like his tests, considers only aspects of

language behavior, is less valuable than his theory. Although he opposed

extreme mechanical views of localization of function like those of Hen-

schen and Kleist, he considered lesions in the lower portion of the pre-

central and post-central convolutions associated with verbal aphasia. The

association between area of lesion and the nominal and semantic classes

of aphasia was less definite. Head argued that intellectual capacity is

not primarily affected, but he admitted that in proportion as "symbolic

formulation and expression" are necessary for the perfect exercise of

psychical aptitudes, general intelligence undoubtedly suffers.

Goldstein (1910) early opposed the classification of the aphasias into

ioio PERSONALITY AND THE BEHAVIOR DISORDERS [32

specific defects like alexia (inability to read), agraphia (inability to

write), aphemia (inability to speak) or amnesic aphasia (loss of memory

for words), and he opposed the attempt to localize such specific acts

within the cerebrum. He has repeatedly pointed out that, when the ex-

amination (1939a) is extended to cover as many aspects of the individual

patient's behavior as possible, disturbances of these specific acts never

occur alone. 31 His tests include form-perception (Gelb and Goldstein,

1920) and sorting and manipulating (now somewhat standardized, see

Goldstein and Sheerer, 1941) as well as language tests and observations

of general behavior. He has observed a wide assortment of behavior dis-

orders in patients ordinarily classed as aphasic. They employ "round-

about" methods of action such as tracing a figure with finger or head

movements or responding with "that is for drinking" instead of with

"cup" when shown a cup and asked what it is. They also show : rigidity

of point of view, inability to carry on a simple course of action once it is

interrupted, a tendency to become agitated and fearful and more than

usually inept when presented with once simple tasks that they can no

longer do. This last type of disturbance Goldstein (1939a) terms "cata-

strophic" behavior, and he interprets such characteristics as fanatical

orderliness and avowed disinterest in many situations as methods of

escaping this catastrophic embarrassment. For Goldstein (1926, 1927),

all these alterations of behavior are manifestations of a single basic change

in the total personality of patients with cerebral lesions. He does not

deny that the locus of the lesion determines some manifestations of this

basic disturbance, but the basic disturbance follows lesions anywhere in

the cerebrum. In this Gestalt view he stands at the opposite extreme

from Henschen and Kleist.

This single basic change in the total personality is conceived as a loss

of capacity to assume the "categorical" or "abstract" attitude which un-

derlies : the voluntary assumption of mental sets, the detachment of the

ego from the outer world or from inner experiences, the reflective shift-

ing from one aspect of a situation to another, the holding of several

aspects of a situation simultaneously, the formation of hierarchic con-

cepts, the capacity of planning ahead or of thinking and performing sym-

bolically (Goldstein, 1939a, 1940; Goldstein and Sheerer, 1941). Only

in the sense that Goldstein's conception of the disturbance in aphasia

involves a symbolic process does it agree with Head's. Goldstein's con-

tribution is great, but his emphasis on extensive studies of individual

patients affords no statistical information and lends itself to over-

generalization.

Weisenburg and McBride (1935) have made the first study of

aphasics that employed a battery of tests involving both language and

nonlanguage functions previously standardized on a group of normal

individuals comparable to the patients in age, education, and occupational

31 See: Gelb and Goldstein (1920, 1924), Goldstein (1922, 1926, 1927, 1928) and

for rapid summaries in English see: Goldstein (1940, Chs. 3 and 4, and 1942) or

Goldstein and Sheerer (1941).

32] PSYCHOLOGICAL DEFICIT ion

status. They also limited the aphasic group to clear-cut cases uncompli-

cated by any other disorder, and employed a second control group of

patients with unilateral cerebral lesions without aphasia. The study was

carried out because Weisenburg had found normal individuals who failed

some of Head's tests, and because he was dissatisfied with Goldstein's

generalizations. From the percentile-profiles of performance, Weisen-

burg and McBride classified their 60 aphasics into four groups. ( 1 ) The

predominantly expressive group (which showed defects in articulation

and in the formation of words with less pronounced limitations in re-

ceptive functions, in the higher language functions, and in the various

nonlanguage tests) was largest (43.3%), had the best prognosis, and

had lesions localized largely in the anterior or motor part of the dominant

hemisphere. (2) The predominantly receptive group (which showed

more or less serious disturbances in the perception and understanding of

spoken language and printed material with less serious disturbances in

the expressive functions) was second largest (28.3%), had an uncertain

prognosis depending on the nature of the lesions which were also local-

ized in the anterior portion of the dominant hemisphere but involved

the posterior portion to a greater extent. (3) The expressive-receptive

group (in which all language functions were severely and equally dis-

turbed) constituted 20% of the sample, had a prognosis definitely poor,

and had lesions involving a larger portion of both the anterior and pos-

terior parts of the dominant hemisphere. (4) The amnesic group (where

the defects lay primarily in inability to evoke names of objects, condi-

tions, and qualities) constituted only 8.3% of the sample, and the locus

of the lesions was indefinite. Contrary to Goldstein's findings, these

amnesic patients usually recognized the correct word when they pro-

duced it accidentally or when it was suggested to them. They showed

defects on nonlanguage tests, but none commensurate with those on lan-

guage tests. Because the functional defects produced by similar lesions

showed great individual variations, Weisenburg and McBride opposed

strenuously the theories of specific localization of Henschen and of Kleist.

Because these disturbances were never confined to the language func-

tions, they disagreed with Head's interpretation of aphasia as a specific

disturbance of language functions. On the other hand, because their

aphasics cooperated well, remained socially adjusted to a high degree,

and showed the greatest defect in language-tests while the patients with

unilateral lesions showed the greatest defects in nonlanguage tests, they

found no basis for assuming such a fundamental disturbance as Goldstein

described as a universal basis for aphasic phenomena. Unfortunately,

however, Weisenburg and McBride, in choosing tests that lent themselves

to quantitative scoring, failed to include any of Goldstein's tests of form-

perception or of sorting.

While there is considerable agreement among the results and interpre-

tations of Head, of Goldstein, and of Weisenburg and McBride, the dis-

agreements argue that the fundamental nature of aphasic disturbances is

still inadequately conceived. Psychologists concerned with learning and

ioi2 PERSONALITY AND THE BEHAVIOR DISORDERS [31

its underlying neural basis should not be surprised at the individual func-

tional variability produced by similar lesions. The performances, lin-

guistic and nonlinguistic, involved in the various tests must be products

of the individual's past behavior. What a priori basis is there for assum-

ing that a given instrumental habit or skill should have the same archi-

tectonic organization in the cortex of every individual when it is well

known that different cues and different muscle systems may serve the

same instrumental acts in different individuals and in the same indi^

vidual at different times?

"ABSTRACT" BEHAVIOR IN NONAPHASICS WITH CEREBRAL LssiONS. 32

Goldstein's generalization that cerebral lesions always produce disturb-

ances of what he calls "abstract" behavior is partially based on the work

of Weigl (1941) and of Nadel (1938). When they gave all tests except

the Vigotsky to patients with cerebral lesions, and included normal sub-

jects which Nadel matched for age and education, defects appeared in all

their patients. Normal subjects often started by sorting objects in such

series as they had seen in concrete situations, but they shifted readily to

the "categorical" approach and usually appeared to prefer it. His general-

ization, but not necessarily his conception of the deficit as "abstract" be-

havior, is also supported by the work of Halstead (1940) who gave his

own sorting test to patients after brain-surgery, by the work of Hanf-

mann and Kasanin (1942) who used the Vigotsky in a study involving

24 patients with "organic" psychoses, by the work of Cleveland (1942)

where the sorting test was given to 20 senile patients, by the work of

Nichols and Hunt (1940) with a case of partial bilateral frontal lobec-

tomy of very superior original ability who failed the Vigotsky and was

unable to do double alternation, and by the work of Hollingworth (1930)

and Conkey (1938) using a hierarchy of tests with cases of traumatic

32 Since we shall refer to them frequently, we give a brief description of the

main performance tests of "abstract" ability (see Goldstein and Sheerer, 1941).

The Goldstein-Sheerer cube-test was designed to determine whether a subject can

analyze a small colored figure well enough to copy it in larger size with Kohs

blocks. Their stick-test was designed to determine whether a subject can copy

figures composed of sticks and reproduce them from memory. Unless the pattern

resembles some commonly experienced object like a roof, such a performance is

assumed to involve an abstract concept of direction in space. The Gelb-Goldstein

color-sorting test was designed to determine whether a subject can sort the Holm-

gren wools according to color concepts. The Weigl color-form test consists of a

dozen blocks in three shapes and four colors. It was designed to determine whether

a subject can shift from one of these categories to the other when told to sort the

objects another way. The Weigl object-sorting test consists of 30 objects which are

randomly arranged on a table. It was designed to determine whether a subject can

sort them according to general concepts, shift these concepts, and discover the prin-

ciple in groupings presented by the experimenter. The Vigotsky test of concept

formation (Hanfmann and Kasanin, 1942) was originally designed to study schizo-

phrenic thinking (Vigotsky, 1934), but it has been adopted by Goldstein and his

collaborators. This test consists of 22 objects in five geometrical shapes, in five

colors, and in four sizes. The subject has to sort these 22 blocks into four cate-

gories, each of which is named with a nonsense syllable. As he sorts, he is corrected

until he has arrived at the definition of the categories (small-tall, small-flat, large-

tall, large-flat), or has had them all placed for him, whence he is asked to formulate

the principle verbally-

32] PSYCHOLOGICAL DEFICIT 1013

head injury. A possible exception to this generalization appears in the

work of T. Hunt on the frontal lobotomy patients of Freeman and Watts

(1942). Of her psychotics 45% actually improved on the stick test after

the operation cutting the pathways between the frontal lobes and the

thalamus. Only 10% were poorer. These findings are inconclusive, how-

ever, because only the stick test was employed and these patients were

already severely psychotic before the operations were performed.

A number of investigators have opposed Goldstein's dichotomy of

"abstract" and "concrete" abilities. Halstead (1940), who developed a

nice technique of scoring his own sorting test, found patients who sorted

into categories like "pictures" or "round things," yet they were distinctly

poorer than controls in the percentage of objects spontaneously grouped,

and they recalled fewer of the objects after five minutes. Bolles (1937)

described four levels of "abstract" ability, and Hanfmann and Kasanin

(1942) found at least three levels of performance on the Vigotsky. Cleve-

land (1942) found individual differences in sorting capacity and followed

Wegrocki (1940) in considering a hierarchy of ability for abstracting

and generalizing. The case of partial bilateral frontal lobectomy reported

by Nichols and Hunt (1940) succeeded with most of Goldstein's tests,

but he failed the Vigotsky, double-alternation, and complex arithmetic

progressions. It was possible to teach him to do both of the former, but

impossible to teach him to do arithmetic progressions that involved sus-

taining more than two tasks simultaneously. He learned, for instance, to

do series like (1-2-4-7- ) by writing in the differences between succes-

sive numbers. This process yielded two separate series, the main series

and that composed of these differences (1, 2, 3, ). These he had to

manipulate conjointly in order to comply with the instruction to keep

the main series going, and thus the main task appeared to resolve itself

into two separate tasks for this patient. On the other hand, this patient

did not learn to do a series like (30-29-27-24- ) even when the num-

ber of items was increased and practice with series after series was given.

Keeping the opposed directions of the main series and of the series of

differences straight during their conjoint manipulation was more than

he could manage. Similarly, complicating the main series so that its

breakdown resulted in three separate series, e.g., (1-2-4-8-15- ) made

it too difficult for him. All these results argue for a hierarchy of "ab-

stract" ability which Goldstein now accepts (Goldstein and Sheerer,

1941).

While Goldstein's theories of "abstract" ability have led to much fruit-

ful work, to us "abstract" ability is still unsatisfying as a concept. We

should like to reduce every aspect of deficit to a truly measurable variable.

Rate of performance and rate of learning would be readily quantifiable

merely by using time as the variable. Rigidity of set or attitude should

be readily quantifiable in a similar fashion. The results obtained by

Nichols and Hunt (not all of which are given in their paper, 1940) point

toward the possibility of defining the "power" aspect of the capacity

required for these performances in terms of the number of tasks or lines

ioi4 PERSONALITY AND THE BEHAVIOR DISORDERS [32

of activity that a person can sustain simultaneously or synthesize into a

single complex operation.

Many concepts appear to involve such a synthesis. For example, learn-

ing to count, where the verbal habit of saying numbers in a given order

is synthesized with touching objects consecutively. Probably number

concepts become "meaningful" only after such a synthesis has become

habituated. Inability to learn to count and to form number concepts,

as is sometimes seen in the feebleminded, 33 may be attributed to a lack of

the fundamental capacity (see definition in footnote above), required for

such a synthesis. And in turn, this lack of fundamental capacity may

perhaps be attributed to an absence of the necessary neurological sub-

strata. The fact that individuals who receive brain injuries early in life

develop vocabularies below their level on the Stanford-Biiiet and on per-

formance tests (Hebb, 1942) fits this hypothesis. Furthermore, from an

introspective analysis, the sorting tests appear to require that one sustain

several tasks simultaneously. It is not surprising, in this connection,

that performance at the highest level on the Vigotsky is limited almost

entirely to college people (Hanfmann and Kasanin, 1942), for college

serves both to select the capable and to habituate such syntheses. We

would consider the deficit found in patients with cerebral lesions who

cannot learn given types of performance as one of fundamental capacity,

and tentatively we should like to conceive this deficit in capacity in terms

of a rigidity of set and a reduction in the number of tasks or lines of

activity that can be sustained simultaneously or synthesized into a single

complex operation. Such a conception should stimulate research along

another line. The chief defect of the notion lies in defining a "task"

or a "line of activity" for experimental work, but this may not prove

unfeasible.

For patients with cerebral lesions who can relearn performances, on

the other hand, the requisite fundamental capacity cannot be considered

destroyed. Aphasics frequently relearn to recognize objects, to name

them, and the like, and to what extent other deficits might yield to train-

ing is still unknown. When performances reappear, either the healing

of tissues or the reorganizing of the skills or habits, e.g., the language

habit, over new architectonic arrangements might conceivably account for

their reappearance.

THOUGHT IN SCHIZOPHRENIA. Nearly all work on thought and lan-

guage in the "functional" psychoses has concerned schizophrenics, and

most of the investigations of schizophrenic thinking in controlled situ-

ations are very recent. Consider first the basic empirical phenomena.

A number of deficiencies have appeared repeatedly in tasks involving

language. The majority of schizophrenics fail to sustain a task or a

33 Based on unpublished work by S. B. Williams who found he could not get

many of his feebleminded subjects at Letchworth Village to synthesize the acts ot

nnintiticr tn nhiprts and savincr numbers.

many <_n ma iccuicuunucu auujv^io ai J '

pointing to objects and saying numbers.

32] PSYCHOLOGICAL DEFICIT 1015

topic. 34 This substantiates further the results from the reaction-time

studies. They usually fail to see absurdities or to interpret proverbs. 35

A majority of schizophrenics fail in tasks involving the discernment of

essential differences or the use of analogies (Wegrocki, 1940; Shipley,

1940). They distort the meaning of words, and these distortions of

word-meaning and more especially of topical meaning become more and

more pronounced with successive requests for clarification by the experi-

menter. 36 In these distortions, words take the place of real objects

(Katan, 1938) ; Despert, 1940), or the schizophrenic may use a metaphor

but omit the as though and then slip from the figurative to the literal

meaning of the words used in the metaphor (Muncie, 1937; Woods,

1938). Great individual differences among schizophrenics appear in all

these performances and in the tendencies indicated here.

Nonlinguistic tasks have yielded a related series of deficiencies in the

performances of schizophrenics. On a picture completion test (Healy

PC-II), Hanfmann (1939a) found that most of her schizophrenics re-

sponded like normal subjects much of the time, but occasional con-

spicuous deviations occurred in which they apparently disregarded spatial

relationships, used a concrete object to epitomize the situation repre-

sented, or transposed the picture into reality. On the Vigotsky test of

concept formation, 26 of the 62 schizophrenics in the sample of Hanf-

mann and Kasanin (1942) got scores below the poorest control, and 14

showed a defect comparable to that found in their patients with "organic"

disorders. 37 The poorest of schizophrenics may show no appreciation of

the sorting tasks at all, or they may use "concrete" bases such as putting

together objects commonly seen in kitchen or bathroom, and be unable to

shift to any other like color or shape (Bolles, 1937). On the Vigotsky,

Cameron (1939b) found them including the blotter, the pencil, or even

the experimenter in the task, asking to have the task altered, and showing

incongruities between action and speech such as forming color groups

34 See: Gatewood (1909), Kraepelin (1919), Hunt (1936b), Cameron (1938a,

1939a), and Wegrocki (1940).

35 See the test studies above and: Hadlich (1931), Zeigarnik (described in

Hanfmann and Kasanin, 1942), Hausmann (1933), Hunt (1935), Hanfmann

(1939b), Wegrocki (1940).

36 See: Muncie (1937), Woods (1938), Cameron (1938b), Katan (1939), and

Wegrocki (1940).

37 Hull (1920) appears to have made the first observations of this sort with a

technique similar to that of Ach of the Wurzburg school which was also the fore-

runner of the Vigotsky test, but little attention was paid them until Vigotsky's

(1934) results were translated and Bolles (1937) found deteriorated hebephrenics

showing a deficit on Goldstein's tests of "abstract" ability. Other studies yielding

similar results are: Bolles and Goldstein (1938), Cameron (1939a), and Cleveland

(1942). Predicting the outcome of the shock therapies in schizophrenics from per-

formance on the sorting tests has also appeared promising (Bolles, Rosen, and

Landis, 1938; Goldstein, 1939b; Zubin and Thompson, 1941). Furthermore, symp-

toms such as clinically discerned thought disorders, dilapidated personal appearance,

and hallucinations, all probably related to poor performance on the sorting tests,

have been found associated with poor prognosis in schizophrenics (Terry and

Rennie, 1938).

ioi6 PERSONALITY AND THE BEHAVIOR DISORDERS [32

but describing them by enumerating the shapes. On the other hand,

eleven of those in the sample of Hanfmann and Kasanin performed at

the highest level found among normal subjects with comparable edu-

cation.

INTERPRETATIONS OF THESE RESULTS HAVE VARIED. Failure of

schizophrenics on absurdities, on proverbs, and on the sorting tests have

been seen as the result of a loss of the capacity to generalize (Rawlings,

1921 ; Wentworth, 1923 ; Wegrocki, 1940) or its near equivalents : a loss

of "abstract" ability (Bolles, 1937 ; Goldstein, 1939b) or regression from

the "categorical" thinking characteristic of adulthood to the "complex"

thinking of childhood (Vigotsky, 1934; Zeigarnik; Hanfmann and Kasa-

nin, 1942). Hanfmann (1939b) defended this interpretation by showing

that one schizophrenic, whom she studied extensively, did sustain such

mechanical tasks as copying words or taking an inventory of surround-

ings. Such a view makes loss of "abstract" ability basic, and failure to

sustain a task becomes a secondary "catastrophic" phenomenon. This

interpretation appears to be true for cases of brain injury and the

"organic" psychoses, but considerable evidence argues against this view

of schizophrenic distractibility and uncooperativeness. Failure of schizo-

phrenics to maintain the "set" to respond appeared clearly in the reaction-

time experiments where the task was simple in the extreme. Although

he did not emphasize the point, Wegrocki (1940) described schizo-

phrenics as verbalizing analogies correctly but writing wrong answers

because their uncontrolled associative processes had carried them on by

the time they got pencil to paper. He also reported that a complex task

may serve to control some schizophrenics, for patients who performed

his tests without error lapsed into the characteristic jargon in voluntary

speech. This agrees with Hunt's (1935) finding that schizophrenics

who will start usually succeed in doing fairly complex arithmetic pro-

gressions. Here the situation continually keeps the task before the sub-

ject if he has the capacity to grasp it. On the other hand, in noting

absurdities where the instruction to look for them had to be assumed

voluntarily or maintained over considerable time while the narrative was

being read, they failed miserably. The fact that schizophrenics use meta-

phor in voluntary speech, even though they slide from figurative to

literal meaning of the words, fits this latter interpretation but argues

against Hanfmann's. Cameron's (1939a) finding that "deteriorated"

schizophrenics used a variety of abstract bases in classifying the Vigotsky

blocks also argues against Hanfmann. Furthermore, if "abstract" ca-

pacity as such is lost, as is implied in Kraepelin's conception of dementia,

recovery of performance on the Vigotsky should not occur automatically

with recovery of social interests as Cameron (1938b) observed. A schizo-

phrenic (Lang, 1940), interpreting his own disorder, also argues against

the loss of "abstract" capacity.

Several writers (Storch, 1924; White, 1928) have compared schizo-

32] PSYCHOLOGICAL DEFICIT 1017

phrenic thinking to that of primitive peoples because both manifest such

characteristics (Stephen, 1935) as not being hampered by a need for

consistency, omnipotence of thoughts and wishes, confusion of doing and

thinking, and failure to distinguish between things emotionally identified,

and argued from these common characteristics that schizophrenia is a

regressive disorder. Were the data available, it is likely that marked

differences could be shown in the motivation and in other factors con-

trolling the thinking of schizophrenics and of primitive people.

The contention that schizophrenia is a regressive disorder has led

to direct comparisons of performances by schizophrenics and children.

Vigotsky's (1934) results with the test that now bears his name favors

this hypothesis. His generalizations : that "categorical" thinking appears

regularly with adolescence, and that "complex" patterns of thinking re-

appear in adults when the schizophrenic process disturbs the psycho-

logical systems that underlie concepts, however, have been modified by

other workers using his own method. His dichotomy of thought-forms

has been shown inadequate by Thompson (1941) and Hanfmann and

Kasanin (1942). Thompson found that the number of hypotheses em-

ployed by children increases gradually with age. Hanfmann and Kasanin

found that the highest level on the Vigotsky test was limited primarily to

college-trained people, and that only 26 of their 62 schizophrenics showed

deficit when comparisons were made with controls of comparable educa-

tion.

Other results show clear differences between the performances of

schizophrenics and children. When Cameron (1938b) compared the

productions of schizophrenics on incomplete sentences ending in because

with those of Piaget's children, he found marked differences. Whereas

the children had used "motivation" as the causal principle most fre-

quently (83.5%) with progressively fewer instances of "logical justifica-

tion" (9%) and "cause-and-effect" (7.5%), the schizophrenics used

"cause-and-effect" most frequently (45%), "logical justification" more

frequently (23%) than did children, and "motivation" in only 32% of

their productions. Furthermore, he found severity of disorder unasso-

ciated with increased failures to continue incomplete sentences ending in

although and even though, but it was associated with increased failures

to continue focati^-sentences, even though the use of discordance (al-

though and even though) had appeared much later than the use of

because in the speech of Piaget's children. In another study, Cameron

(1939b) found that children manifested a relative dearth of answers,

while schizophrenics had plenty. Schizophrenics and children both showed

defective logical organization, but while schizophrenics gave worse dis-

tortions vrith requests to clarify without becoming disturbed, children

gave progressively better approximations and did appear distressed by

the experimenter's failure to understand. Cameron considered the de-

fective organization of children due to their not yet having learned from

social necessity to organize according to adult standards, while those

ioi8 PERSONALITY AND THE BEHAVIOR DISORDERS [32

of schizophrenics were attributed to having given up effective social

contact. 38

If one conceives regression as back-tracking over inexorable steps in

a developmental process, Cameron has shown that such a conception of

schizophrenic thinking fails. On the other hand, if one interprets regres-

sion as either the reappearance of older tendencies when newer ones are

extinguished (Mowrer, 1939) or the reversion to "simpler levels of

creative activity" under the influence of frustration (Barker, Dembo, and

Lewin, 1941), the behavior of the immature and the regressed could not

be expected to be alike in all aspects, and Cameron's evidence fails to

apply. From a speculative standpoint, however, we agree that the past

need not supply all schizophrenic symptoms. Many of those substituted

for the socially rewarded responses, which we assume are extinguished,

are probably entirely new to the schizophrenic's life history. 39

Several investigators have used the deficiencies on tests of "abstract"

ability as indirect evidence of cerebral pathology in schizophrenics be-

cause these particular deficiencies appear so characteristically in cases

38 Organic immaturity may also be a factor in these organizational defects in

children's thinking. The gradual improvement in organizational performance with

age in preadolescents (Thompson, 1941) may argue for the importance of a matu-

rational process, although this fact alone might also be explained by assuming that

the skills required for thought-performances are learned slowly. In connection

with a study of children's drawings, Cameron (1938a) points out (1) that naming

objects drawn follows perceptual isolation of forms, and (2) that the younger

child "is unable to fixate the parts and at the same time maintain the original

perspective of the whole." Thus such organizing appears to demand that one sus-

tain several tasks simultaneously and synthesize them into a single operation. If

it is assumed that this capacity demands certain neural structures, the fact that

children live for years with adults without acquiring certain complex types of

performance and then acquire them relatively suddenly may perhaps be attributed

partly to a maturation process. However, to indicate clearly the limitations of this

interpretation, one should not expect primitive peoples to lack the basic capacity

to acquire our adult forms of organization. They lack them because these forms

did not exist in the cultures that nurtured them. Moreover, they would have great

difficulty acquiring ours at adulthood because of the habit interference between

their own and ours. It is also possible to interpret these facts of the development

of reasoning in children as a consequence of the accumulation of the dynamic

effects of habits acquired successively under social motivation. This problem of

intellectual development in childhood begs for analysis. Intelligence testing and

normative studies of stages in performance have been relatively uninformative, and

a strong faith in this latter form of interpretation might produce valuable results

if it were properly oriented. We are ready for an experimental attack upon this

problem that is oriented in modern behavior theory.

39 This general argument that we have reiterated may not apply to all schizo-

phrenics. Schizophrenics constitute an extremely heterogeneous population as they

are diagnosed now, and one day subgroups with structural or physiological pathol-

ogy may be differentiated. Cerebral pathology has already been demonstrated in

individual patients diagnosed as schizophrenic (see Ch. 29 by Cameron). On the

other hand, superficial parallels between schizophrenic behavior and such phenomena

as those shown in sleep (Jung, 1908), in normal individuals under low oxygen

tension (McFarland, 1932), in aphasia (Tatarenko, 1938), and in "organic" psy-

choses (Orton, 1930; Krisch, 1932) are only suggestive at best. Moreover, failure

to recover need imply no organic involvement other than that which must underlie

all learning processes, for recovery could be expected only when the problems

producing the schizophrenic reactions have been resolved, as is argued by French

and Kasanin (1941).

32] PSYCHOLOGICAL DEFICIT 1019

with cerebral pathology. 40 Such evidence is suggestive, but not crucial,

for there are many instances of similar behavior with different deter-

minants. Moreover, Goldstein's basic assumption that "abstract" and

"concrete" abilities are not "acquired mental sets" but "capacity levels

of the total personality" itself seems dubious to us. Undoubtedly these

tests of "abstract" ability require high levels of fundamental capacity, but

good performance on these tests would not arise automatically as a con-

sequence of maturation in a person with the greatest fundamental ca-

pacity. As must all thought processes like classifying, inducing relations,

etc., we should guess that the "abstract" abilities assessed by these tests

involve habitual skills which may be either strengthened or weakened by

an individual's social experience. These skills probably represent a com-

plex accumulation of habits successively acquired. They appear gradu-

ally with age both because the structures upon which fundamental

capacity presumably depends mature gradually and because certain basic

skills must reach a certain degree of perfection before they can be merged

into more complex skills. They may be damaged either by destroying

the structures upon which they depend, or by interfering with their re-

inforcement which is presumably social. We prefer to extend our inter-

pretation of other schizophrenic behavior to schizophrenic thinking, for

the schizophrenic withdrawal from social interaction would remove this

reinforcement. An argument somewhat resembling this one is presented

by Zubin and Thompson (1941), and we should mention that our argu-

ment has roots in Adolf Meyer's (1906) interpretation of schizophrenia.

Furthermore, similarities in the performances of schizophrenics and

"organic" patients and the aged stand out only so long as one considers

success and failure in the tasks presented. When experiments are de-

signed to emphasize factors in the motivation and control of performance,

striking differences appear. The parallels that Kraepelin saw between

the behavior of schizophrenics and patients with senile psychoses are

opposed by Cameron's (1938) finding that senile patients give a con-

siderably higher percentage of logically cogent responses to incomplete

statements ending in because than do schizophrenics. And more impor-

tant in this context, seniles maintain an attitude of anticipating criticism

and retain the social amenities to a greater extent than do schizophrenics.

We have already noted that when schizophrenics and "organic" patients

perform repeatedly on the same tasks, the "organic" patients show less

variability in both attitude and output than schizophrenics. The contrast

found by Hunt (1935) in the performances of schizophrenics and paretics

on arithmetic progressions and a narrative containing absurdities is also

significant. Although the schizophrenics were slow, if they cooperated at

all, they succeeded in continuing fairly complex progressions, but paretics

failed all but the simplest progressions with the best of cooperation.

Hunt attributed the success of schizophrenics in sustaining the tasks in-

40 See: Vigotsky (1934), Bychowski (1935), Bolles and Goldstein (1938), and

Goldstein (1939b).

1020 PERSONALITY AND THE BEHAVIOR DISORDERS [32

volved in these arithmetic progressions to the fact that the process of

doing progressions continuously instructs the subject if he is capable.

Squires (1936) has added that the schizophrenic may succeed because

these arithmetic tasks are unrelated to the schizophrenic's "diseased feel-

ings and emotions/' It appears, thus, that the differences in this per-

formance are attributable to differences in fundamental capacity. On the

other hand, schizophrenics failed invariably to note absurdities in the

narrative during the first reading with only the instruction to read it, or

during a second reading with the instruction to make improvements in

the narrative ; and only about half of them noted absurdities at the third

reading when instructed explicitly to look for them. Moreover, those

who failed at this stage usually attempted to explain away the absurd-

ities. 41 But paretics, if they could continue any progressions beyond the

highly practiced multiplication tables, objected to absurdities when they

first read the narrative with such statements as: "Fir trees don't have

leaves," or "You don't harvest in March." It appeared that schizo-

phrenics were distracted from the content of the narrative or from sus-

taining the task of looking for absurdities by possible preoccupations, or

even that they actively resisted finding absurdities. This "withdrawal"

of the schizophrenic could sometimes be overcome with pressure from

verbal instructions. The paretics needed no such pressure. Their marked

readiness to discern absurdities is perhaps another manifestation of the

"extratensive" tendency of patients with brain pathology uncovered by

the Rorschach (Piotrowski, 1937; T, Hunt in Freeman and Watts,

1942). Studies designed to emphasize the various factors controlling

performance are too few to be more than suggestive, but they argue

clearly for different bases for the deficits in schizophrenia and in the

"organic" conditions. More of such studies are needed, and they should

be based on adequate samples of patients from all diagnostic groups.

Summary and Conclusion Concerning the Nature of Deficit

1. Pseudo-measurements of deficit with standard tests have shown

some degree of deficit in all the disorders except, possibly, the psycho-

neuroses, in the aged, and in patients with surgical brain injury. The

deficit is largest in the "organic" psychoses, but some schizophrenics,

particularly those of the hebephrenic subgroup, show deficits as large as

those in the "organic" disorders. The present tests of intelligence and

deficit are not so well adapted as the tests of "abstract" ability to uncover

the deficit following surgical brain injury, but the latter are still not well

standardized nor have they been well adapted for scoring.

2. Tests of vocabulary and information are failed least often, and tests

41 Unpublished extensions of this work have shown similar tendencies in manic-

depressive patients. They have also indicated that schizophrenics tend to note

"logical" absurdities ("Because the rabbit ran faster than I did, I could overtake

it only slowly and finally caught it"), while "organic" patients note those "based

on experience" ("fir trees with leaves" or "harvesting in March") which the schizo-

phrenics sometimes attempt to explain away.

32] PSYCHOLOGICAL DEFICIT 1021

involving conceptual thinking, sustained associative thinking and speed

are most regularly failed. In the feebleminded and in cases of brain

injury in infancy the pattern of success and failure differs considerably

from that in the disorders and that following adult brain injury. Al-

though the patterns in "functional'* and "organic" disorders show many

similarities, there are some interesting differences.

3. In studies of specific aspects of behavior the evidence of deficit con-

sistently becomes more pronounced as either receptive or expressive

performances become more complex.

4. Although schizophrenics show excessive variability in the expres-

sive indicators of emotion, they show no evidence of "apathy" on

these indicators, and schizophrenic startle reactions are exaggerated.

Evidence of "apathy" shows clearly, however, in the overt behavior of

these patients and appears as a loss of interests.

5. Reversal of the "fatigue effect" with continuous work, slowness of

perceived fluctuations in ambiguous figures, and possibly certain alter-

ations of the patellar reflex appear specifically characteristic of manic-

depressive patients.

6. Evidence of retrograde amnesia in the "organic" psychoses con-

firms clinical observation. Deficit in memorial efficiency appears to be

more a function of aging than psychosis, however, and some evidence

indicates that this deficit is more a matter of impressionability or modifi-

ability than of retention.

7. While the deficit in the aphasias is greatest in performance in-

volving language, it is certainly not limited to language performances.

8. Studies of the thought processes, especially those using the sorting

tests and the other tests of "abstract" ability, have brought out marked

deficiencies in patients with "organic" psychoses, with aphasia, with brain

injuries outside the speech-areas, and with schizophrenia.

9. So long as one looks only at the success of patients on these

thought tasks, the deficiencies in schizophrenics appear similar to those

in the "organic" conditions, but differences appear when experiments

are designed to bring out motivation and other factors controlling per-

formance.

10. In reviewing these investigations of deficit, we have developed

the hypothesis that intelligent behavior and thinking are dependent upon

both fundamental capacities and learned skills. These fundamental

capacities we conceive to be based somehow on neural structures and to

consist behaviorally of ready modifiability of response and of capacity to

sustain several attitudes or tasks simultaneously, to shift readily from one

to another, and to synthesize them into a single complex operation. In

order for such capacities to be manifest in test-situations, the skills in-

volving them must have been learned. We conceive these skills as

higher-order habits acquired through and continually reinforced by the

individual's social living. We admit that knowledge of these thought

skills and of how to teach them constitutes a hiatus in the field of psy-

chology. The deficit shown in the "organic" psychoses, in the aged, and

1022 PERSONALITY AND THE BEHAVIOR DISORDERS [32

in cases of adult brain injury we should attribute largely to damage to

the neural structures underlying these performances. Such a deficit may

show as reduced modifiability, as inability in performances where many

attitudes or tasks must be sustained simultaneously or in performances

that involve shifting readily from one attitude to another. Those deficits

from which the structurally damaged individual recovers with training

may be conceived as resulting from damage to the architectonic arrange-

ments through which these particular performances are organized. The

fundamental capacity upon which they depend is not ruined so long as the

performances can be relearned, which presumably must involve either

healing of tissue or new architectonic arrangements. The deficit in the

"functional" psychoses, and particularly in schizophrenia, we conceive

as an extinction of standards for performance and of thought skills that

have been socially rewarded. The deficit in these disorders is also

complicated by conflicts between response tendencies and by distraction

from idiosyncratic preoccupations which arise as substitutes for the

socially rewarded skills and responses.

11. In the future, we should like to see more experiments to bring

out differences in the factors controlling performance, and we should

like to see every technique applied to representative samples of the

whole gamut of disorders and conditions. Only then can the conclusions

of today be denied, or verified or amplified.

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Chapter 33

ELECTROENCEPHALOGRAPHY

By DONALD B. LINDSLEY, Ph.D.

PERSONALITY, IN ITS BROADEST SENSE, may be construed to mean a

totality of behavior based upon interdependent structural and functional

components of a living organism. Behavior may be defined to include

any change or adjustment made by the organism, either in whole or part,

to internal and external environmental influences. Therefore the many

faceted thing we call personality (see Chapter 1 by MacKinnon), and its

disorders, may be approached from many angles. One approach is

through the electrical changes which serve as signs of underlying physi-

cochemical conditions associated with metabolic and other processes dur-

ing relative states of rest as well as during activity induced by stimula-

tion.

All living tissues possess electrical properties which are subject to

study in terms of familiar units of electrical measurement, and the brain

is no exception. In the study of personality and behavior aberrations

the newly developed technique of electroencephalography, which deals

with the recording of electrical potentials from the brain, is of impor-

tance in the differentiation of individuals and in the measurement and

evaluation of response to internal and external environmental influences.

An attempt will be made in this chapter to survey the results of a

number of investigations which have utilized the method of electro-

encephalography to study behavior and its disorders in the human

organism. No attempt will be made to review the results of the many

animal experiments which have contributed so extensively to the

methodology and background of information necessary to the under-

standing of the results in human studies.

History. The recording of electrical potentials from the brain of

man began in 1924 with the work of Hans Berger, a German neuro-

psychiatrist. Prior to that time, for a period of SO years, scattered

reports appeared in the literature describing observations of electrical

activity in the exposed brains of animals. These early studies (for refer-

ences see Jasper, 1937; Walter, 1938; and Gibbs and Gibbs, 1941)

attracted little attention, partly because electrical phenomena associated

with nervous activity were little understood at the time and partly

because the potentials were so minute that their details could not be

adequately registered by available recording instruments. Berger 's inter-

1033

1034 PERSONALITY AND THE BEHAVIOR DISORDERS [33

est in these early observations led, after some preliminary experimenta-

tion with animals, to the study of human subjects. After five years of

work, he published in 1929 the first report of human brain potentials.

Because of his interest in psychiatry and neurology Berger quickly

sought to apply his newly discovered technique to the study of patho-

logical conditions in man, but not without first attempting to determine

the nature of the phenomenon, the limitations of the technique, and the

characteristics of the electrical activity of the brain in normal indi-

viduals. He demonstrated that the more or less continuous rhythmic

fluctuations of potential recorded from electrodes attached to the scalp

at the front and back of the head arose from the brain tissue and were

not due to circulatory pulsations, muscle activity, or other extraneous

factors. He was able to show that the electrical activity of the brain is

modified by sleep, anesthesia, and various forms of sensory stimulation ;

that the patterns of activity vary with age in young children ; and that

certain pathological conditions produce abnormal manifestations of the

electrical record from the brain. These and other original observations

are described in his extensive series of publications (1929 to 1938).

Adrian and Matthews (1934a) in England were the first to publish

confirmation of Berger's findings, and Gibbs and Davis (1935), Jasper

and Carmichael (1935), and Loomis, et al. (1935a, 1935b) in America

soon added further proof. In the meantime information concerning the

electrical activity of the central nervous system of animals was rapidly

accumulating. Interest in the work spread rapidly to other parts of the

world, new apparatus and techniques were developed, and many publica-

tions of animal and human investigations appeared.

Early reviews of the subject, dealing principally with results of animal

studies have been presented by Fischer (1932), Kornmuller (1935c),

and Gozzano (1935). More recent and more extensive reviews, includ-

ing human electroencephalography, are those by Kornmuller (1937a),

Jasper (1937), Berger (1938a), Bremer (1938a), Davis, H. (1938b),

Fessard (1938), Liberson (1938), Walter (1938), Rohracher (1938b),

Bertrand, et al. (1939), and Gibbs and Gibbs (1941). The last named

review is in the form of an Atlas and presents many records illustrative

of normal and pathological conditions.

Electroencephalography in pediatrics has been reviewed by Byers

(1941) and Brill (1942), and its use in psychological studies has been

discussed by Kreezer (1938b) and Knott (1941). Workers in many

different lands have published, in several different languages, discussions

of technique, method and applications, usually coupled with descriptions

of their own preliminary results. Lack of space does not permit the

listing of all of these but some of the more representative are : Schackter

(1936), Cucchi (1938), H. Davis (1938a), Godlowski (1938), New-

man (1938), Asenjo (1939), Cottenot and Liquier (1939), Davis and

Davis (1939), Rohracher (1939), Aguero y Montoro (1940), Caprile

and Gascon (1940), Spielberg (1940a), H. Davis (1941), P. A. Davis

(1941e), and Carrillo (1941).

33] ELECTROENCEPHALOGRAPHY 1035

Articles dealing particularly with clinical applications are : Baudouin

and Fischgold (1938, 1939), Golse (1938), Kornmuller (1938), Balado,

et al (1939), Dalsgaard-Nielsen (1939), Goodwin and Hall (1939),

Hyland, et al (1939), Jung (1939a, 1941), Kornmuller (1939),

Schmelvkin (1939), Torrents (1940), Walter (1940a), Pacella and

Barrera (1941), Prados y Such (1941), Ramirez Moreno (1941),

Serota and Grinker (1941), Yeager and Walsh (1941), and Gibbs

(1942b).

Nature of Phenomenon. Berger's discovery that the human brain

during a relative state of rest, in the absence of specific stimulation, has

an electrical beat or rhythm of its own was surprising indeed, so much

so that his results were looked upon with considerable skepticism until

confirmed by others. However, some preparation for understanding the

electrical phenomena of the brain had already developed from the results

of animal studies. For example, slow, rhythmic potential waves were

recorded from isolated ganglia of the caterpillar and water beetle by

Adrian (1930, 1931) and in the isolated brain stem of the goldfish by

Adrian and Buytendijk (1931). Isolated from other parts of the nervous

system and cut off from sources of sensory impulses the brain stem oi

the goldfish produced slow, rhythmic potentials which were correlated

with respiratory movements of the gill slits. Here was evidence in the

central nervous system of rhythmic electrical activities of spontaneous

and autonomous origin, controlled presumably by metabolic processes,

and resembling the automatic regulation of activity in the nonnervous

embryonic heart. Further evidence of automaticity in the isolated frog

brain has been presented by Libet and Gerard (1938, 1939, 1941).

At the time of Berger's discovery of human brain rhythms consider-

able was known about the characteristics of electrical potentials asso-

ciated with the nerve impulse, but this type of activity, associated with

discrete events such as the passage of the nerve impulse in response to

sensory and reflex stimulation, did not appear to be of immediate sig-

nificance for the interpretation of the electrical changes emanating from

the complex network of axons, dendrites, cell bodies, and supporting

structures of the brain. The potentials from the brain consisted of con-

tinuous, often sinusoidal, rhythmic variations of different frequencies

and patterns. Instead of being initiated by specific stimulation, the

rhythms appeared to be of spontaneous and autonomous character and

were in fact diminished or abolished temporarily by certain types of

sensory stimulation. For a good discussion of the nature of autonomous

rhythms of the brain and the factors which affect them, see particularly

the papers presented at a symposium by Bishop (1936), Davis (1936),

Gerard (1936), Hoagland (1936b), and Jasper (1936b).

It was possible to rule out extraneous sources of electrical activity

such as potentials originating in scalp, face and neck muscles, static

potentials of the eyeballs, circulatory pulsations, and so forth (Berger,

1929; Adrian and Matthews, 1934; Jasper and Andrews, 1936, 1938a;

1036 PERSONALITY AND THE BEHAVIOR DISORDERS [33

Lyman, 1941). However, one must always be on guard against artifacts

produced in these ways. The influence of sensory stimulation, sleep,

anesthesia, and so forth in modifying the rhythmic potentials served to

demonstrate the nervous character of the electrical activity and even

suggested a cortical origin. Recording directly from the surface of the

brain at time of operation (Berger, 1935a; Foerster and Altenburger,

1935 ; Walter, 1936 ; Schwartz and Kerr, 1940; Scarff and Rahm, 1941)

furnished more direct proof of the cortical origin of the potentials.

These studies showed also that the type of activity recorded from the

surface of the scalp was very similar to that recorded from electrodes

in direct contact with brain tissue except that on the surface of the skull

the patterns of activity were less well localized and were greatly reduced

in amplitude. The amount of reduction is of the order of 5 to 1 in the

rabbit (Kornmuller and Janzen, 1939b), but in man is considerably more

according to Walter (1936) who reports potentials of the order of 1 to

10 millivolts on the surface of the cortex as opposed to 10 to 100 micro-

volts on the surface of the scalp. This reduction is undoubtedly due to

the increased resistance and diffusion caused by the scalp and skull.

Some idea of the manner of diffusion or spread of the potentials on the

surface of the scalp from a localized source in the brain has been pre-

sented by Adrian and Yamagiwa (1935) who experimented with an

artificial source of potential in the skull of a cadaver, and by Andrews

(1938) who discussed the physical basis of brain potentials from theo-

retical and applied points of view.

In spite of the clinical and experimental usefulness of the electroen-

cephalogram and the numerous studies which have added to our infor-

mation concerning it, many questions still remain with respect to the

fundamental nature and specific origin of the potentials. For example,

do the potentials originate in cell bodies of cortical neurones or do they

represent axonal, dendritic or synaptic activity ? What gives rise to the

rhythms of different frequencies and different patterns ? What is the role

of the various cortical layers, the cytoarchitectural variations from one

part of the cortex to another, or the ascending, descending, and tangential

pathways in the cortex ? How many neural units are required to produce

an electrical disturbance which may be recorded at the surface of the

scalp ? What determines the combination and apparent synchronicity of

cellular discharges? What is the relationship between the apparently

autonomous and spontaneous rhythms of the resting cortex and evoked

potentials produced by specific afferent stimulation? How are the

potential rhythms of the various areas of the cortex related to one

another? Are there fixed or shifting centers of control, that is "pace-

makers," in the cortex which serve to integrate the activities of the

different parts, or are cortical electrical activities regulated principally

by thalamic and other subcortical centers ?

Partial answers to some of these questions have already been pro-

vided by results of animal studies and additional evidence is rapidly

accumulating. It is now generally believed that the spontaneous poten-

33] ELECTROENCEPHALOGRAPHY 1037

tials of the cortex originate principally in nerve cell bodies (Bartley and

Bishop, 1933; Bishop, 1935; Bremer, 1938b, 1938c; Libet and Gerard,

1938, 1941 ; Rosenblueth and Cannon, 1942) rather than in the axons.

There is evidence from lesions circumscribing certain areas that some

spontaneous rhythms of the cortex originate in local regions and are

relatively independent of other parts of the cortex (Bartley and Bishop,

1933; Bremer, 1938b, 1938c; Gerard and Libet, 1939, 1940; Rosen-

blueth and Cannon, 1942). There is also reason to believe that "loop"

or "reverberating" circuits between thalamus and cortex are necessary

to the maintenance of certain types of spontaneous activity (Bishop,

1936; Bishop and O'Leary, 1936; Dempsey and Morison, 1942; Rosen-

blueth and Cannon, 1942). In fact the work of Dusser de Barenne and

McCulloch (1938) indicates that even more complex circuits are in-

volved, including certain nonthalamic nuclei. Incoming impulses from

sensory receptors must be properly integrated at both thalamic and

cortical levels with spontaneous rhythms in these circuits in order to be

effective and evoke maximal cortical response.

With respect to the role of different cortical layers Dusser de Barenne

and McCulloch (1936) have shown that spontaneous potentials of the

cortex are practically abolished by thermocoagulation of the outer three

layers of the cortex and are completely and permanently abolished by

destruction of the four outer layers. Kornmiiller (1935c) maintains

that there are differences in the bioelectric activity of different parts of

the cortex, corresponding to the architectonic fields. Similar gross differ-

ences have been pointed out in man (Jasper and Andrews, 1936, 1938a;

Laugier and Liberson, 1937; Rubin, 1938a), although the distinction

between areas is greatly reduced when the potentials are recorded

through the scalp and skull.

Most workers have agreed with Adrian and Matthews (1934a) that

summation of discharges of individual neurones is necessary for the

production of potentials sufficiently large to be recorded from the surface

of the scalp. Adrian and Matthews (1934b) in attempting to record

cortical response from individual neurones concluded that the slow,

rhythmic cortical waves are summations of temporally dispersed faster

components in individual neurones. On the other hand Renshaw, et al.

(1940) using microelectrodes to record unit responses from the hip-

pocampus of the cat found both slow and rapid potential fluctuations.

On the basis of their data it is not possible to decide whether cortical

rhythms are composed of summations of individual neurone discharges

of the same slow frequency, or are built up by synchronization of many

fast components. An interesting paper on the interaction and integration

of neuronal activity has been presented by Gerard (1941).

Despite the lack of a clear understanding of the nature and origin

of the potential rhythms recorded from the surface of the scalp, the

electroencephalogram possesses certain measurable and discriminable

characteristics which may be utilized in clinical and experimental studies.

Caution must be urged, however, against too much theorizing before an

1038 PERSONALITY AND THE BEHAVIOR DISORDERS [33

adequate understanding of causal or underlying factors has been attained.

It is highly desirable for those working with the human electroen-

cephalogram to keep in close contact with the results of electrophysi-

ological investigation in the animal field.

Terminology. The record of the electrical activity from the brain of

man was called by Berger (1929) an Elektrenkephalogramm. The Eng-

lish equivalent is electroencephalogram. The abbreviation is EEG.

Other designations used in published studies are brain potentials and the

more popular rubric, brain waves. Berger originally recorded the poten-

tials from across the entire surface of the head, with one electrode

attached to the forehead and the other at the back. Investigators have

since come to use several electrodes more closely spaced so as to record

from relatively localized regions corresponding roughly to the anatomical

subdivisions of the brain. Tracings from electrodes placed over different

areas of the brain are therefore designated as occipital EEG, frontal

EEG, and so forth. In order to distinguish between records from the

surface of the scalp and those obtained with electrodes in direct contact

with exposed portions of the brain, the former are referred to as

electroencephalograms and the latter as electrograms. Thus there may

be cortical electrograms, cerebellar electrograms, or thalamic electro-

grams, depending upon the part of the exposed brain from which the

potentials are derived.

Types of Waves in the EEG and Their Characteristics. Berger

(1929, 1932b) found in the EEG of normal adults two types of waves

which were distinguished by their frequency, amplitude and differential

response to sensory stimulation. The larger, rhythmic waves averaging

about 10 per second and subject to modification by stimulation, he called

alpha waves. The more rapid, less prominent waves, often superimposed

on or forming a background for the alpha rhythm, he called beta waves.

ALPHA WAVES. Berger (1933d, 1935a, 1936, 1938c) held that alpha

waves originate in all parts of the cortex, whereas Adrian and Matthews

(1934a), and Adrian and Yamagiwa (1935) concluded that the source

or focus of the alpha waves was in the neighborhood of area 19 of the

occipital lobes. The evidence which follows indicates that Berger 's view

was more nearly correct, although it is true that in most normal subjects

the strongest and most persistent alpha rhythm is found over the

occipito-parietal regions. Cortical electrograms in man (Foerster and

Altenburger, 1935 ; Scarff and Rahm, 1941) have revealed alpha rhythms

in all regions of the cortex, but predominantly over the various sensory

fields. Likewise the distribution of the alpha rhythm over the surface

of the scalp has been shown by Liberson (1937), Jasper and Andrews

(1938a), Loomis, et al. (1938), and Rubin (1938a) to be widespread

and to have simultaneously differential features over the occipital,

temporal, and frontal areas. Lindsley (1938b), using a phase reversal

localization method similar to that employed by Adrian and Yamagiwa.

33] ELECTROENCEPHALOGRAPHY 1039

demonstrated separate foci for the alpha rhythm in occipital, occipito-

parietal, parieto-frontal, and temporal regions.

Smith (1939, 1941) has shown that the occipital and precentral alpha

rhythms in infants and young children first appear at different times and

have different developmental sequences. The alpha rhythm over the

sensory-motor regions is present at birth and has a frequency of 7 to 8

per second (Smith, 1938a, 1941), whereas the occipital alpha rhythm

first appears in the third or fourth month at a frequency of 3 to 4 per

second (Lindsley, 1936, 1938a, 1939; Smith, 1938b, 1939). The fre-

quency of the precentral alpha rhythm increases very little during the

first year, but the occipital alpha rhythm increases rapidly; after the

first year both rhythms increase at similar rates and attain an adult

frequency level at about ten to twelve years of age.

The normal range of frequencies for the alpha rhythm in adults,

regardless of the region of the head, is 8 to 13 per second. Occasionally

slightly higher or lower frequencies are found, but they are usually con-

sidered as suggestive of abnormality. For children below ten years of

age a lower range of frequencies must be accepted as normal, due to the

change in frequency with age. The voltage level of the alpha waves is

difficult to specify since it varies with the position and distance between

electrodes, as well as with the use of bipolar and monopolar recording

methods. 1 Typical of the relative voltage levels for occipital and pre-

central alpha rhythms are the following results recently obtained by the

author in a group of 20 normal, young adult men. Using a bipolar

method, with electrodes 5 centimeters apart, the mean occipital alpha

wave voltage was 24 microvolts, the range for individual subjects was

9 to 48; the mean for the precentral alpha rhythm was 13 microvolts

with a range from 8 to 23 (unpublished data). Monopolar recording

methods result in greater voltages than bipolar (see Figure 1). The

voltages given here are in essential agreement with those reported by

others (Davis and Davis, 1936; Jasper and Andrews, 1936). The

usual limits cited for alpha voltages are from 5 to 100 microvolts ; alpha

voltages in excess of the upper limit are frequently pathological.

BETA WAVES. There is a wide diversity of opinion concerning the

origin, characteristics and significance of the beta waves. This is partly

due to the fact that their voltage is low, the frequency high, and the

pattern somewhat irregular. These characteristics lead to difficulty in

adequately recording and measuring the beta waves and make them

easily confused with action potentials from muscles of the scalp. In addi-

tion they are not readily affected by factors which modify the alpha

1 In the case of the monopolar system of recording, one electrode is placed on

the scalp over an "active" region of the brain, the other electrode is attached to a

supposedly "inactive" or "indifferent" region, such as the lobe of the ear or mastoid

process. With the bipolar system both electrodes are attached to the scalp, usually

about five centimeters apart, over "active" regions of the brain. There are advan-

tages and disadvantages of both systems ; these have been discussed by Tonnies

(1934), Jasper and Andrews (1936), Jung (1939a), Kornmuller and Janzen

(1939b), Kornmuller (1940a), and Gibbs and Gibbs (1941).

1040 PERSONALITY AND THE BEHAVIOR DISORDERS [33

rhythm. As a consequence most investigators have not found it profitable

to study them extensively.

Most workers agree with Jasper and Andrews (1936, 1938a) that

beta waves are more prominent over the precentral and frontal regions

of the brain than elsewhere, although like the alpha waves they are

found to some extent over all regions. Recording directly from the

cortex at time of operation Scarff and Rahm (1941) found beta waves

predominating in the frontal regions of the brain. Berger (1932b, 1936,

1938c) has reported the frequency of beta waves to range from 20 to

more than 100 per second, but he does not agree with Rohracher (1935,

1937c) and Gemelli (1937) that they may attain frequencies of 1,000

to 2,000 per second. Since others have failed to observe such high fre-

quencies it seems likely that they are due to some source of artifact.

According to Jasper and Andrews (1938a), who have made the most

systematic observations of beta waves, the frequency range is pre-

dominantly from 18 to 30 per second with a mean of about 25 per

second; the voltage range is from 5 to 20 microvolts. Unlike the

occipital alpha rhythm, which is temporarily blocked by visual, and to

some extent by other types of sensory stimulation, the beta waves are

not markedly affected. Jasper and Andrews (1938a) state that tactual

and auditory stimuli may affect the beta waves without producing an

effect on the alpha waves. This result does not, however, seem to have

been confirmed generally. Strong, sudden, unexpected stimulation of

"startle" character may block the beta waves temporarily.

GAMMA WAVES. Very low amplitude beta-like waves of 35 to 45

per second, noted particularly over the precentral and frontal regions,

were tentatively labelled gamma waves by Jasper and Andrews (1938a).

No special response characteristics have been described for these waves

and their significance is not known. The term is not commonly used.

Adrian and Matthews (1934a, 1934b) were of the opinion that beta

and alpha waves represent discharge potentials from the same cellular

units, the alpha waves representing a more fully synchronized discharge.

A number of observations might be interpreted as consistent with this

point of view. Of the various cortical regions, beta waves are most

prominent and alpha waves least prominent in the precentral and frontal

areas. This may be due to the fact that the precentral and frontal regions

are more highly differentiated in terms of the variety of functions they

subserve and hence less subject to synchronized activity than are the

sensory projection fields, where the alpha rhythm is strong and the beta

rhythm feeble. Likewise sensory stimulation in blocking or disrupting

the alpha rhythm frequently leaves only the smaller, faster beta-like

waves. Because of this Adrian and Matthews (1934a) have concluded

that sensory stimulation has a desynchronizing effect on groups of cells

beating in unison. Also consistent with a common origin of beta and

alpha waves might be the observations of Jasper and Andrews (1938a),

that the frequency of both types of waves is increased by elevation of

33] ELECTROENCEPHALOGRAPHY 1041

body temperature, and by Lindsley (1938a), that alpha and beta waves

show essentially parallel increases in frequency as a function of age in

young children.

Berger (1938c) does not believe that alpha and beta waves have a

common origin. He thinks that they originate in different types of cells

in the different cortical layers ; the alpha waves coming from the deeper

pyramidal cell layers and the beta waves from the superficial layers of

the cortex. He cites the results of Bremer as indicating that beta waves

arise from the small ganglion cells of the superficial layers. As a conse-

quence of his observations that only the alpha waves are modified or

reduced in amplitude by sensory stimulation, shifting of attention, sleep,

anesthesia, stupor, and various disease processes, Berger (1930, 1932b)

concluded that alpha waves are a reflection of biological activities asso-

ciated with psychophysical processes and that beta waves are an expres-

sion of nutritive and metabolic functions. Precisely the opposite view

has been proposed by Rohracher (1938b) and Alberti (1941).

In addition to alpha, beta, and gamma waves, a number of other fre-

quency components have been observed in the EEG of normal adults,

at rest, with the eyes closed. Grass and Gibbs (1938), and Gibbs

( 1942a) have presented cortical frequency spectra 2 showing some

degree of energy represented at each frequency level from 1 to 60 cycles

per second. The greatest amount of energy is found at the low fre-

quency end of the spectrum ; there are also energy peaks corresponding

to the mean frequency level of the alpha and beta waves. Other less

prominent peaks indicate the presence of other frequency components ;

some of these plus other abnormal distributions of energy in the spec-

trum are useful for detecting pathology and results of this character

will be presented later. The application of names to particular rhythms

detected by the wave analyzer or by observational analysis of the EEG

has not seemed warranted since there are all gradations of voltage and

considerable overlapping of frequency bands. As a consequence it is

more accurate to describe rhythms in terms of their frequency, ampli-

tude, and patterned characteristics.

DELTA WAVES. One additional designation, applying particularly to

abnormally slow waves found in pathological records, but present also

in the records of normal subjects during sleep and certain other physio-

logical states other than the normal waking one, is that of the delta

waves. This term was used originally by Walter (1937) to designate

the abnormal, slow waves of large magnitude, usually of 2 to 3 per

second or less, found in the region of brain tumors and serving as a

2 Frequency spectra are distributions of energy at each frequency level from 1

to 60 cycles per second. Known as a Fourier transform, the method has been

described by Grass and Gibbs (1938). Briefly, it consists in recording the EEG

as a shadowgram, making a belt of one meter of the record and revolving it before

a beam of light and a photo-cell. The resulting voltage fluctuations are then passed

through a variable electric filter and the output rectified and recorded as energy at

each frequency level.

1042 PERSONALITY AND THE BEHAVIOR DISORDERS [33

means of localizing the tumor. The name delta waves is now commonly

applied to all slow waves with a frequency less than about 8 per second,

the lower limit of alpha waves in normal adults. A different criterion

is necessary in the case of children, whose alpha waves may be slower

than 8 per second. Except during sleep and certain other specifiable

conditions, delta waves are considered indicative of abnormality. They

occur in a variety of pathological conditions of the brain, of both physio-

logical and anatomical nature.

In certain types of pathology the EEG may be characterized by out-

standing deviations from normal in the form of single waves of peculiar

shape or of waves repeated in rhythmic or nonrhythmic patterns, such

as spikes, multiple spikes, spike and slow wave complex, saw-toothed

waves, square-topped waves, and so forth. These are usually further

qualified, if possible, by measurements of magnitude and duration. Thus

abnormality of the EEG may be appraised in terms of a number of inde-

pendent factors as well as in terms of combinations of these factors.

Abnormality may be determined by rhythms that are too fast as well as

too slow, by voltages which are too low as well as too high, and by

amounts of activity ranging from zero to 100% presence in a given unit

of the record.

Methodology.

Although no two investigators follow precisely the same procedure in

recording the human EEG, there has gradually evolved a certain measure

of standardization so that general comparability of results is attained.

Despite differences in the number of electrodes used and their placement

on the head, differences in amplifiers and recording 1 systems, variations in the

position and condition of the subject during the recording of the EEG, the

results obtained in various laboratories are in fairly close agreement.

ELECTRODES AND THEIR ARRANGEMENT. The main requirements for

electrodes are that they be good conductors, that they make adequate con-

tact with the surface of the scalp through an electrode paste or some other

electrolyte solution, that their position may be made secure so that drying

of the electrolyte or shifting of contact is prohibited, and that they may be

worn by the subject without discomfort. A common type of electrode con-

sists of flattened or cup shaped pellets of solder (Gibbs and Gibbs, 1941),

of about 5 to 10 millimeters in diameter, or similar sized silver electrodes

which may be chlorided and made relatively nonpolarizable (Jasper and

Andrews, 1938a). Polarization is relatively unimportant, however, since

current flowing in the circuit is extremely small and alternating. After the

locus for the electrodes has been determined by appropriate measurement,

a small amount of hair is cut to allow the electrode to fit snugly against

the scalp surface and the scalp is cleaned with a solvent, such as acetone, to

remove oil and sebaceous secretions. The electrodes are held in place by

means of collodion. Flexible, insulated wire of small gauge leads from

each electrode to a plug-in board and thence by insulated cable to a switch

box where different combinations of electrodes may be selected.

There is no standard system of electrode placement or leads, such as there

is in the field of electrocardiography, but most workers have certain cri'

33] ELECTROENCEPHALOGRAPHY 1043

teria, based on measurements with respect to anatomical landmarks of the

skull, which enable them to state clearly the location of their leads. There

is usually a similarity of arrangement of electrodes on the surface of the

scalp so that representative samples of electrical activity may be obtained

from the various regions of the head. Systematic arrangements of elec-

trodes for routine clinical examination, or more detailed localization studies

have been described by Jasper (1941) and by Gibbs and Gibbs (1941).

LOCALIZATION METHODS. The first step in localization consists in noting

regional deviations from normal expectancy. A comparison of the activity

from bilaterally homologous areas is important for detecting unilateral

abnormalities. Two specific methods for fairly precise localization within

a single hemisphere have been described. One is the phase reversal tech*

nique (Adrian and Matthews, 1934a). Electrodes are usually closely spaced

and arranged in line so that each successive electrode is connected to

two different amplifying and recording systems. The leads from each elec-

trode are so oriented with respect to the input connections of the two

amplifiers that an electrical disturbance of a given potential sign originating

under an electrode common to two amplifying- recording systems produces

waves of reversed phase in each tracing. With several electrodes in line

and a multiple recording system the focus of a localized abnormal disturb-

ance usually may be readily detected by noting the region under an elec-

trode which is common to two reversed tracings. The method of triangula-

tion (Jasper and Hawke, 1938) consists of placing electrodes on the scalp

in such a manner as to represent three corners of a triangle; a focus of

disturbance near a corner of the triangle is reflected by phase reversal in

the tracings from the two amplifying and recording systems connected to

the electrode in that region. Differences in the magnitude of the disturb-

ance recorded from electrodes bounding the three sides of the triangle are

also useful in localizing the focus of abnormality.

For localizing abnormalities in subcortical regions, particularly at the

base of the skull in the region of the hypothalamus, Grinker (1938) intro-

duced a basal lead. The basal electrode, consisting of a long pointed wire,

insulated except at its tip, is introduced through the nostril until its pointed

tip is imbedded in the periosteum of the sphenoid bone at the back of the

pharynx. Grinker and Scrota (1938), Hoagland, el al. (1938b), and Grinker

(1939) have used this technique, particularly in the study of emotional

states and their apparent hypothalamic correlates. Jasper (1941) described

a slight modification of the technique and its application in conjunction

with triangulation to points on the surface of the scalp, in the localization

of diencephalic abnormalities. A clear description of the various localiza-

tion methods, with illustrative records and diagrams, has been presented

by Jasper (1941).

REQUIREMENTS OF AMPLIFIERS AND RECORDING SYSTEMS. Since the volt-

ages recorded from the surface of the scalp, except in certain pathological

cases, are for the most part less than 100 microvolts, considerable degree

of amplification is necessary. This may amount to as much as a million-

fold, depending upon the sensitivity of the recording unit. The amplifiers

must magnify, without appreciable distortion, potentials varying in duration

from more than one second to one-sixtieth of a second or less. The over-all

frequency-response characteristics of the amplifying and recording system

1044 PERSONALITY AND THE BEHAVIOR DISORDERS [33

should be uniform, with a constant input voltage, over a range of fre-

quencies from less than one to at least 60 per second, or more if higher

frequencies are to be studied.

The most common amplifier in use is of the push-pull type and resistance-

capacity coupled, with large enough coupling condensors to accommodate

slow potential changes. Direct coupled amplifiers are ideal from the point

of view of fidelity of response, but frequently lack stability. Details con-

cerning required characteristics and amplifier design may be found in the

following reference sources: Tonnies (1932, 1938), Garceau and Davis

(1934, 1935), Matthews (1934, 1938), Jasper and Andrews (1936), Loomis,

et al. (1938), Jung (1939b), Rahm (1939), Torrents (1939) Herrnfeld and

Sjaardema (1940), and Goodwin (1941).

A variety of recording units have been used. Berger's early studies

were made with a sensitive string galvanometer without amplification.

After amplification became available, less sensitive instruments were used.

Cathode ray and mirror, or galvanometer type oscillographs are useful but

require photographic recording. The more recently developed inkwriting

oscillographs, either of the crystal or electromagnetic types, because of their

convenience and economy are now most widely used. From one to six or

more of these inkwriting units may be arranged to trace records simultane-

ously, from as many regions of the head, on paper tape moving at a uniform

rate.

PROCEDURE. After the electrodes have been cemented to appropriate re-

gions of the head the subject reclines on a cot, or sits quietly and relaxed

in an electrically shielded and relatively sound-proof room so as to be free

from external stimulation and distraction. Either the room is darkened or

the subject closes his eyes, for visual stimulation disturbs the pattern of

activity from the brain. Tracings of electrical activity from different com-

binations of head regions are obtained during a period of 15 minutes to a

half hour or more depending upon the nature of the study and the time

available. Ordinarily to make a careful examination of a patient, especially

where localization of abnormality is necessary, a period of at least an hour

is required, including the time spent in putting on and taking off 10 or more

electrodes and in obtaining a systematic series of records. It is desirable

to have an observer stay with the subject to note and signal movements

and other characteristics of behavior which might introduce artifacts or

serve as useful correlates of the electrical changes produced in the record.

EVALUATION OF THE EEG. For most clinical purposes, the experienced

electroencephalographer familiar with normal and abnormal variations of

the EEG can readily detect the pathological features of the record. How-

ever, for more detailed study and analysis for experimental purposes there

are several, quite precise, quantitative measures of the different character-

istics of the record which may be made. Among these may be mentioned

frequency or the average number of waves per second, amplitude or the

average voltage in terms of microvolts, and per- cent-time or the amount of

time that certain types of waves are present during a substantial unit of

the record. The latter measure when applied to the alpha rhythm is fre-

quently referred to as per-cerit-time alpha, or alpha index, but may also be

applied in the case of other types of waves, especially the abnormally slow

or delta waves.

33] ELECTROENCEPHALOGRAPHY 1045

Hoagland, et al. (1937a, 1937b) devised a method, known as the delta

index, for determining the excess length of one meter of record contributed

by the voltage component of waves slower than alpha waves. This was

done by running a map measurer over the crest and trough of all waves of

greater duration than alpha waves of about 8 per second, but along the

linear axis or baseline wherever alpha waves were present. Variations of

this method for measuring the slow wave components of the EEG are the

delta excess (Davis and Sulzbach, 1940), which included the excess length

of record contributed by waves slower than 5 per second; the Wellenindex

or wave index (Jung, 1939a), a product of the duration (in tenths of a

second) and voltage (in tenths of a millivolt) of the slowest and most

prominent waves recurring at least three times in every 10 second unit of

record; and the abnormality index (Strauss, 1942) derived by the formula:

P X V/IQF, where P equals per-cent-time delta, F the lowest delta fre-

quency, and V the highest voltage of F in microvolts. The method devised

by Grass and Gibbs (1938) for plotting the energy in various frequency

components of the EEG, known as a cortical frequency spectrum or Fourier

transform has already been described.

A method of classifying the patterns of activity of the EEG on a quali-

tative basis, principally in terms of the prominence, persistence, and regu-

larity of the occipital alpha rhythm, was first described by Davis and Davis

(1936). Alpha rhythms present more than 75% of the time were labeled

dominant; 50 to 75%, subdominant; 25 to 50%, mixed; and below 25%,

rare. Voltage and regularity usually decreased with amount, and beta and

low voltage slow waves were sometimes observed in the mixed and rare

classifications. A further elaboration of this system, giving more weight

to quality and types of rhythms than to voltage or per-cent-time, was later

presented by P. A. Davis (1941e).

Methods of measuring the phase relationships of alpha waves from

bilaterally homologous areas have been described by Travis and Knott

(1937c), Jung (1939a), Lindsley (1940a), and Therman (1940).

The Electroencephalogram in Normal Individuals

The EEG of the typical normal adult subject when awake, but at rest

and relaxed, in the dark or with eyes closed and in the absence of

specific stimulation shows a more or less continuous series of rhythmic

waves. These are composed principally of alpha and beta waves, whose

characteristics and limiting features have already been discussed. Since

the alpha waves in most subjects and in most areas of the head constitute

the outstanding part of the picture, the discussion which follows will be

concerned principally with them. Furthermore, since the alpha rhythm

is more prominent over the occipital lobes of the brain than elsewhere

in most subjects and since the majority of studies deal primarily with

the occipital alpha rhythm, most of what follows will have reference to

the occipital alpha rhythm unless otherwise specified.

Inter- and Intra-Individual Differences. As previously stated, the

alpha rhythm in different normal adult subjects ranges in frequency

from 8 to 13 per second, with a mean of about 10 per second; voltage

ranges from 5 microvolts or less to about 100 microvolts, with a mean

1046 PERSONALITY AND THE BEHAVIOR DISORDERS [33

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of about 25 for bipolar methods to perhaps 40 to 50 microvolts by mono-

polar methods ; the per-cent-time or alpha index varies from almost zero

to 100%. From these facts it may be gathered that there is considerable

range of individual variability, but in addition there are also variations

in the pattern of the waves, ranging from almost complete arrhythmicity

consisting of mixtures of alpha and beta waves of irregular dimensions,

to extremely rhythmic and regular wave forms. In addition a pattern

of rhythmic alpha waves may show variable periods of waxing and

waning, sometimes shifting abruptly and in other cases showing a

smooth modulation of amplitude. Some of these characteristics aic

illustrated in the EEC's of different normal adult subjects shown in

Figure 1. These individual differences have been confirmed by numer-

ous workers who have studied groups of normal adult subjects (Berger,

1930, 1931 ; Davis and Davis, 1936; Jasper and Andrews, 1936, 1938a;

Loomis, et a/., 1936b; Lemere, 1936, 1941; Lindsley, 1936, 1938a;

Liberson, 1937, 1941; Rubin, 1938a, 1938b; and others).

Whereas interindividual variability among normal subjects is clearly

apparent, intraindividual variability tends to be small. The EEG of the

individual person during the course of a single recording period shows

moment to moment variations in frequency, amplitude, and pattern and

no particular section of the record appears precisely like another. Yet

as the record streams on and on, one cannot help being impressed with

the high degree of similarity all the way through. Averages of fre-

quency, amplitude, and per-cent-time from meter to meter of record

show very narrow variability. Variability in frequency of the alpha

rhythm from day to day, month to month, or even longer intervals

seldom exceeds 2 cycles per second and is usually less than 1 cycle per

second (Loomis, et al., 1936b; Jasper and Cruickshank, 1937; Jasper

and Andrews, 1938a). Lindsley and Rubenstein (1937) recorded

EEC's in four young adult women for 32 consecutive days and found

that the standard deviation of alpha frequency for any one subject did

not exceed .47 per second, which means that daily variations were for the

most part less than 1 cycle per second. Liberson (1937) found intra-

individual variability of alpha wave amplitude significantly less than

interindividual variability among 80 normal subjects. Rubin (1938b)

studying the variability of the EEC's in normals and schizophrenics

found that both groups show insignificant variations in per-cent-time

alpha, number of alpha bursts, and average length of alpha bursts within

an experimental session and only slightly greater deviation from day to

day.

Travis and Gottlober (1936, 1937), studying the consistency and

individuality of EEC's, conclude "that not only can an individual be

distinguished from other individuals by his brain potentials, but under

relatively constant experimental conditions an individual's brain poten-

tials are highly consistent from day to day." Davis and Davis (1936)

note that different persons show different patterns of activity and that

each tends to reproduce his own characteristics. However, they main*

1048 PERSONALITY AND THE BEHAVIOR DISORDERS [33

tain that the individuality is not as complete as that of a finger-print,

due to the dynamic factors involved. They studied the EEC's of 8

pairs of identical twins (18 to 58 years of age) and found the records

as similar as those of the same person at different times; also they

found certain unique features of a record common to both members of

a twin pair. They conclude that the EEG "reveals some inborn feature

or pattern of cerebral activity. The pattern is labile, to be sure, but the

degree of lability seems to be one of its inborn characteristics." Davis

(1936) has suggested that the individuality of the EEG may represent

a cortical organization which has an hereditary basis. The similarity

of EEC's in twins has also been noted by Loomis, et al. (1936b).

Raney (1939) studying 17 pairs of identical twins noted both greater

qualitative and quantitative similarity of their EEC's than for those of

unrelated children, but stressed the fact that the differences held mainly

for groups and that some twin pairs deviated as widely as nontwins.

Furthermore, he pointed out that the EEC's recorded from both sides

of the head in identical twins show a reversed bilateral asymmetry cor-

responding to reversed laterally, and that in some twins the bilateral

differences exceed those in nontwins.

Further evidence of the expression of heredity in the brain wave

pattern has recently been adduced by Lennox, et al. (1942), who studied

70 pairs of twins. Among S3 "normal" pairs were 41 twin pairs said

to be monozygotic ; 35 of these were judged to have identical EEC's,

5 were doubtful, and 1 pair showed definite dissimilarity. In 5 dizygotic

pairs of the same sex, the EEC's were dissimilar in 4 and similar in one.

In 7 pairs of opposite sexed twins, the EEC's were obviously dissimilar

in all. For the whole group of 53 twins, the EEG similarity or dis-

similarity agreed with the correspondence of physical characteristics in

87%, was doubtful in 9%, and disagreed in 4%. Among 17 twins, with

a history of epilepsy or brain injury in one or both members of a pair,

certain abnormal features of the EEC were common to both members,

even though one was clinically "normal." Other evidence that path-

ological features of the EEG may be inherited has come from studies of

epileptics and their relatives (Lennox, et al., 1939, 1940b, 1942; Lowen-

bach, 1939; Strauss, et al., 1939; Robinson, 1940). Gottlober (1938b),

on the other hand, studied the EEC's of the father, mother, and two

or more siblings in each of 15 families and found no characteristics of

the alpha rhythm which were significantly related within family groups.

With a view of determining whether individual differences in brain

wave activity are persistent under differing conditions, and therefore

indicative of a fundamental or inborn characteristic, Knott, et al. (1939)

studied two groups of subjects with diverse waking patterns under the

additional condition of sleep. There was no high relationship between

individual differences awake and asleep, and there was a greater sim-

ilarity of individual records during sleeping than during waking condi-

tions. Henry (1941a), following up this approach, studied 20 subjects

with distributed alpha indices, making them a heterogeneous group with

33] ELECTROENCEPHALOGRAPHY 1049

respect to amount of alpha activity. He found that the various sleep

rhythms they displayed during an all-night sleep period were more

nearly alike than their daytime waking records; also that their alpha

indices immediately after waking in the morning were not as widely

distributed as during daytime records, thus making them a more nearly

homogeneous group. Actually the means for the early morning records

were approximately the same as for the daytime records, the principal

change being one of a tendency of regression toward the mean.

In another study Henry (1941b) used four subjects representing

different quartiles of the alpha index distribution and compared their

alpha indices during various "psychological activities" such as silent and

oral reading, talking, and resting with eyes open and closed. Certain

of the "psychological activities'* tended to reduce the amount of indi-

viduality exhibited in the EEC's. It was concluded that environmental

factors, as well as inborn characteristics may determine the amount of

alpha activity in the EEC.

Although the results of the Knott and Henry studies are interesting,

it may be questioned how much relevance they have for the problem of

whether the individuality of the patterns and characteristics of the EEC

are rooted in factors of biologic inheritance. It would seem that the

physiological states involved in the conditions they studied include too

many uncontrolled variables which may directly or indirectly modify the

electrical activity of the brain. On the other hand, it would be sur-

prising indeed if the cortical organization, assumed by some to be inborn

and accountable for the variations in EEC patterns, were not also modi-

fied by numerous secondary factors, which tend to obscure hereditary

likenesses. The interdependence of so many anatomical, physiological,

and psychological factors as components in the structure and dynamics

of personality, makes any single variable difficult to find and to assess in

relation to personality. The striking interindividual differences in the

EEC, like so many other individual differences in physical and mental

characteristics, offer plentiful lure, but so far little substantial bounty,

to those seeking personality correlates. The following studies represent

attempts to relate the EEC to certain aspects of personality.

Personality and the EEG. Lemere (1936), assessing EEC's on a

qualitative basis, according to whether they showed "good" alpha waves

(constant, regular, and over 50 microvolts) or "poor" alpha waves

(variable, irregular, and below 50 microvolts), studied 26 normal per-

sons and 40 psychotic patients. Using a psychiatric classification, both

patients and normals were separated according to cyclothymic or

schizoid make-up. He concluded that "good" alpha waves were asso-

ciated with the former and "poor" alpha waves with the latter. Apathy

or affective deficiency of schizophrenics seemed to him the feature of

the illness most clearly related to "poor" alpha wave production ; whereas

emotional instability and lability manifest in disseminated sclerosis and

manic-depressive patients appeared closely related to "good" alpha

1050 PERSONALITY AND THE BEHAVIOR DISORDERS [33

waves. Similar personality characteristics in normals were said to be

associated with either "good" or "poor" alpha wave production, which

Lemere assumed was based on constitutional factors. Elsewhere (1939,

1941 ) he has presented similar results based on larger groups of normals

and patients, but has dealt principally with the supposed physiopatho-

logical mechanisms of the latter and has said little about the personality

and EEG relationships in the former. His explanation for the EEG

dichotomy in patients will be discussed later under psychiatric disorders.

Lemere's results in schizophrenic and manic-depressive patients have

not been strongly reinforced by others (Berger, 1937c) ; McMahon and

Walter, 1938; Davis and Davis, 1939; Jasper, et a/., 1939; Davis,

1940b; Finley and Campbell, 1941; Walter, 1942), although this is

possibly due to different approaches to the problem. Yeager and Baldes

(1937), using the Davis EEG classification scheme, reported that a high

percentage of their dementia praecox patients had EEC's of the "rare"

or "mixed" type of patterns, and that manic-depressives and involutional

melancholies had a tendency toward a "dominant" type of pattern. This

seems to be in essential agreement with Lemere's results.

In normal persons Gottlober (1938a) studied certain personality

traits in relation to the EEG. Of 67 subjects judged by subjective rating

and the Nebraska Personality Inventory to be either extraverted or

introverted, he found that 82% of the former had a "dominant-sub-

dominant" or high alpha wave type of pattern and 18% had a "mixed-

rare" or low alpha pattern ; 57% of the introverts had high alphas and

43% low alphas. He concluded that individuals showing a high degree

of extraversion tend to show a "dominant-subdominant" alpha rhythm,

but indicated that it could not yet be stated that introverts show pre-

dominantly a "mixed-rare" type of alpha pattern. Henry and Knott

(1941), repeating Gottlober's study with 40 men and 40 women and

using the Nebraska Personality Inventory to classify their subjects

according to degree of extraversion or introversion, did not obtain the

same results. In fact their results showed a tendency to the reverse of

Gottlober's. Only 43% of their extraverts had high alphas whereas

60% of the introverts also had high alphas. The relation between intro-

version and a high alpha index was not statistically significant.

Lindsley (1938a) in the course of another study had data available

on three possible aspects of personality, namely, intelligence (Stanford-

Binet and Otis tests), dominance or assertiveness (Allport's Ascendance-

Submission Test), and emotional stability (Woodworth-Mathews' Per-

sonal Data Sheet) for 88 normal children of ten to fourteen years of age.

These he correlated with per-cent-time alpha and a qualitative rating of

the pattern of the EEG based on a system similar to the Davis classifica-

tion. No significant relationships were found.

A psychoanalytic approach has been utilized by Saul, et al. (1937), in

the search for correlates of the individuality of the EEG pattern. Using

the alpha index as a measure of the EEG, 31 individuals undergoing

psychoanalysis were retested after an interval of seven months. Twenty-

33] ELECTROENCEPHALOGRAPHY 1051

five showed alpha indices on retest agreeing with original indices within

10 points; only two deviated by more than 17 points. All deviations

greater than 10 points were in the direction of a lowered alpha index on

retest, but there was no relationship between these changes and the

clinical changes reported by the analysts. Alpha indices were determined

for 66 persons while in process of analysis or just following completion

of analysis. The same type of distribution of alpha indices was found as

for a group of 200 normals; the indices were evenly distributed from

zero to 100%.

These investigators then attempted to correlate alpha index with the

emotional and instinctive trends revealed by psychoanalysis. They con-

cluded that two opposing trends correlated with low and high alpha

indices. A low alpha index was said to go with a trend toward activity

and a high alpha index with a trend toward passivity or inhibition.

Behaviorally these trends were revealed by the individual's habitual

actions and attitudes toward persons, food, work, sleep, and sex. A high

alpha index was said to be associated with a passive, dependent, re-

ceptive attitude toward other persons. Such a person works to satisfy

desires but under protest ; desires and requires more than the average

amount of sleep ; has a dependent attitude toward women, especially the

mother ; when thwarted may develop temper tantrums or a depression ;

dreams of inactivity, inhibited activity, or rejected activity and other

passive, receptive states. Such individuals are described as solid citizens,

and patient workers and planners. A low alpha index is associated with

consistent, well-directed, freely indulged drives to activity ; a "reaction-

formation" against passive desires ; an active "masculine" trend amount-

ing to nonovert homosexuality in women which expresses itself in

dreams, masculine dress, and other forms of competition with men ; also

dreams of activity are common. An independent, aggressive person, who

is a leader in social activities, who is a Joer in reality rather than in in-

tellectual sublimation, and who is impatient for gratification of instinctual

impulses, is described as the type of individual who might be expected to

have a low alpha index. It is pointed out, however, that these "active"

and "passive" types are not entirely unmixed or rigidly restricted to

high and low alpha indices. The relationship is more in the nature of a

trend or tendency.

Following up the approach of Saul and collaborators, Rubin and

Bowman (1942) studied a group of 100 peptic ulcer patients. They

recorded EEC's from the occipital area and obtained personality data

by interview, particularly with reference to such factors as work attitude,

parental identification, attitude toward mate and friends, and a child-

hood history. Using the Davis classification system they found about

70% of their patients fell in the "dominant" EEG category, whereas

among a normal population only about 20% are so classified. Twenty

per cent of their patients were classified in the "rare" or low alpha group.

Since the majority of their patients show a "dominant" pattern they con-

clude, on the basis of the study by Saul, et al. (1937), that there is a

1052 PERSONALITY AND THE BEHAVIOR DISORDERS [33

relationship between peptic ulcer and a passive, receptive personality

structure. In support of this they offer their personality data, which

they believe indicates that the peptic ulcer patients are in general a

dependent, mother-identifying group as children and adolescents. On

approaching maturity the high and low alpha groups develop differently,

the former continues to be dependent on a mother surrogate, but the

latter manages to achieve independence, through a strong "reaction-

formation" to an underlying passivity. It was claimed that more of the

high or "dominant" alpha group held their jobs over a prolonged period

and more of them were passive toward their mates.

Berger (1938c) states that it is a peculiar fact that the feebleminded

frequently have "better" (probably meaning more prominent and more

rhythmic and regular) alpha waves than intelligent persons. This he

believes is due to a more automatic cortical function, or an undisturbed

passive stream of ideas less interfered with by external and internal

stimuli. He contrasts a "passive EEG" of this type with an "active" one

in a state of attention or mental work where alpha waves are diminished

and there is more of a tendency toward beta waves. He states that it is

more difficult for an intelligent person to stay "passive" long, and as a

consequence there is a tendency for such a person to have a "mixed

EEG" composed of "active" and "passive" parts. Hence children, feeble-

minded, and primitive people tend to show the best resting alpha waves.

In a study utilizing the EEG for purposes of professional selection,

Liberson (1941), using frequency, amplitude, and the Davis classifica-

tion of pattern as measures of the EEG, compared his results on 168

subjects, ranging from low rank to engineers, with a biometric profile

consisting of a variety of physiological and psychological measures. He

found that those with EEC's classified in the "mixed" category fell below

the average for the group on the biometric profile, whereas those in the

"dominant" group fell above, particularly in sensory functions, memory,

vital capacity, and voluntary endurance in apnea. In a variety of other

psycho-physiological functions, including general intelligence, the two

groups were not widely separated. According to Liberson, amplitude

and alpha index classification give the best predictions for separating the

groups according to biometric differences.

Thorner, et al. (1942), using the Grass-Gibbs spectrum analysis

method, have attempted to select aviators for their flying ability on the

basis of the EEG. Flying ability was rated by instructor pilots. Fifty-five

student pilots and 54 pilots were studied. Three types of EEG spectrums

were described. Fifty per cent of the entire group had a type A spectrum

with a simple energy peak in the 5 to 15 per second range; 40% had a

type B spectrum with a narrow or complex energy peak in the 5 to 15

per second range; and 10% had no definite peak in the 5 to 15 per

second range. They conclude that flying ability tends to be high if the

center of the energy peak is about 10.5 per second and falls off as the

energy peak deviates from this value to either side. Other so-called

"abnormal" tendencies were utilized to improve the selection slightly.

33] ELECTROENCEPHALOGRAPHY 1053

Practically all of these studies of the EEC in relation to personality

are characterized by several inadequacies. First of all, from the point of

view of the EEG. Records from one area of the brain are frequently

taken as representative of the whole. More important is the fact that too

little analysis and quantification is attempted ; usually only one measure

is utilized, despite the fact that the individuality of the EEG is contrib-

uted by more than one characteristic, at least three of which are subject

to fairly precise measurement. From the point of view of personality

there is too great a tendency to rely on subjective judgments and ratings,

or to attempt to relate the EEG to an isolated dichotomous trait, which

often cannot be clearly defined and at best represents only a fragment of

the total personality picture. A better approach to the problem would

seem to be to take EEC's from all representative head regions, make a

detailed analysis of each in terms of the measurable characteristics and

then classify or group persons according to the differential features of

their EEC's. A search for behavioral and personality characteristics

common to the persons in each EEG category could then be made, using

various combinations of tests and other methods of evaluation.

Developmental 'Aspects of the EEG.

INFANCY AND CHILDHOOD. Berger (1932c) was the first to note

that the EEG of infants and young children differs from that of adults.

He concluded that the alpha rhythm is not present until the third or

fourth month and that its frequency at onset is low, but increases with

age. This was confirmed by Loomis, et al. (1936b) and Lindsley (1936).

The latter studied the development of the occipital alpha rhythm in 100

children ranging in age from one month to sixteen years. Below three

months of age he found principally nonrhythmic potentials of irregular

shape and size, but mainly of low amplitude. Beginning in the third or

fourth month a definite occipital alpha rhythm became apparent at a fre-

quency of 3 to 4 per second. The frequency of the rhythm increased

rapidly during the first year, being about 5 to 6 per second at one year,

but increased somewhat more slowly thereafter and attained an adult

frequency level at about eight to ten years. The onset of the rhythm at

about three months was thought to be associated with certain developing

visual perceptive functions, and the increase in frequency with age to

be related to myelinization or other developmental growth processes.

Subsequent studies (Lindsley, 1938a, 1939; Smith, 1937, 1938a,

1938b, 1939; Bernhard and Skoglund, 1939a, 1939b; Brill and Seide-

mann, 1941), based on large groups of children of all ages, have estab-

lished age norms for frequency and amplitude, and have noted other

developmental characteristics of the EEG. All are in agreement that

there is a definite frequency growth curve for the occipital alpha rhythm

which has a logarithmic form. Weinbach (1938a) fitted data obtained

by Lindsley and Smith on frequency growth of the alpha rhythm in

children to equations representing other biologic growth processes. He

also pointed out that the decline in time-rate of increase in alpha fre-

1054 PERSONALITY AND THE BEHAVIOR DISORDERS [33

quency is a constant, probably a genetic one constant for each species.

Weinbach (1938b) and Lindsley (1938a) have called attention to the

similarity of the curves of growth of brain weight and the rate of growth

of the occipital alpha frequency.

Smith's extensive studies (1938a, 1938b, 1938c, 1939, 1941) of new-

born infants have revealed that several distinct rhythms are present over

the sensory-motor regions at birth, but only when the activity level of

the child is reduced during the initial stages of drowsiness. Prominent

among these is the forerunner of the precentral alpha rhythm at a fre-

quency of 6.5 to 7.5 per second, which does not change greatly during

the first year of life but thereafter increases parallel to the occipital alpha

rhythm. Smith (1941) points out that the earlier development of

rhythms in the sensory-motor regions than in other areas of the cortex

is in accord with the histological evidence of advanced cellular develop-

ment there, also that certain aspects of motor behavior seem to be

correlated with the development of precentral rhythms.

PRENATAL EEG. Lindsley (1942), in the course of recording fetal

heart potentials from the abdomen of the mother, has recorded, during

the seventh month of pregnancy, rhythmic potential waves which he

believes originated in the brain of the fetus. These rhythmic potentials

^ould be recorded from the region over the palpable head of the fetus

only, and corresponded in frequency to the precentral alpha rhythm

observed by Smith in newborn infants. The possibility of recording the

EEG prenatally may have some importance for the correlation of physi-

ologic and histologic development of the cortex ; furthermore it may be

useful for comparison with the EEG shortly after birth in order to

determine the nature of the effects of birth injury.

Psychological Variables and the EEG.

SENSORY STIMULATION. One of the striking demonstrations which

may be made with the EEG is the blocking of the occipital alpha rhythm

with visual stimulation (see Figure 2). Berger (1930) noted that open-

ing the eyes in a lighted room abolished the alpha waves, and that open-

ing the eyes in a dark room did not, although Jasper and Cruickshank

(1937) mention that attempting to see in the dark is sometimes effective.

Since Berger found that other types of sensory stimuli had similar effects

on the alpha rhythm, he concluded that the focusing of attention rather

than special sensory processes is responsible for the blocking of the

alpha rhythm. Adrian and Matthews (1934a) believed that some pattern

or form in the field of vision was necessary for blocking the occipital

alpha rhythm, although they agreed with Berger that attention focused

on a problem will block the rhythm even in the absence of visual

stimulation.

Latency of blocking or the time from the onset of a visual stimulus to

the reduction in amplitude or disappearance of the alpha waves is about

.3 second (Berger, 1932b; Jasper and Cruickshank, 1937; Knott, 1938b;

and others) but varies with the intensity and duration of the stimulus

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1056 PERSONALITY AND THE BEHAVIOR DISORDERS [33

(Durup and Fessard, 1936a, 1936b; Cruickshank, 1937; Ito and Kasa-

hara, 1939) and is reduced slightly by an associated motor response to

the stimulus (Travis, et al., 1937; Knott, 1938b, 1939). Recovery time

or the duration from cessation of the stimulus to the return of the alpha

waves is of the order of 1 second, but likewise varies with the intensity

and duration of the stimulus (Cruickshank, 1937; Jasper and Cruick-

shank, 1937; Motokawa and Tosisada, 1941). Figure 2 illustrates the

variation in blocking and recovery time to flashes of light of constant

intensity, but of varying duration. Persistent, unchanging stimulation for

a period of 10 or 15 seconds or longer usually results in adaptation and

a return of the alpha rhythm, though somewhat sporadically, apparently

depending upon fluctuations of attention (Jasper and Cruickshank, 1937;

Rohracher, 1937c; Spielberg, 1940b).

A variety of modifications of the alpha rhythm may be produced by

flickering visual stimulation of different frequencies (Adrian and Mat-

thews, 1934a; Jasper, 1936a; Loomis, et al., 1936b; Goldman and Segal,

1938; Goldman, et al., 1938; Segal, 1939; A. C. Williams, 1939; Liv-

anov, 1940; Kornmuller, 1940d; Toman, 1941). The alpha rhythm

may be driven at higher and slightly lower frequencies than its normal

rate by a flickering stimulus ; in some cases it is modified in pattern or

may shift back to its original frequency when certain multiples or sub-

multiples of the spontaneous frequency are reached by the flickering

stimulus. Fluctuations of the alpha rhythm were noted by Jasper and

Cruickshank (1937) and Travis and Hall (1938) with the appearance

of after-images following visual stimulation.

Auditory stimulation blocks the occipital alpha rhythm also, but is

less effective than visual stimulation and has a slightly longer latency

(Berger, 1930; Travis, et al, 1937, Gibbs, et al., 1935; Bagchi, 1936;

Durup and Fessard, 1936a; Bakes, 1939; P. A. Davis, 1939; and

others). Sudden unexpected auditory stimuli of moderate to strong in-

tensity may produce prolonged blocking of the alpha rhythm (Berger,

1933a). An auditory stimulus loses its effectiveness after a number

of repetitions (Bagchi, 1936; Lindsley, 1938a; Forbes and Andrews,

1937; Jasper and Shagass, 1941a). The effect of meaningful, verbal

stimulation has been investigated by Bagchi (1936), and Travis and

Egan (1938a). Adaptation to continuous auditory stimulation is more

marked than to intermittent stimulation (Bagchi, 1936; Spielberg,

1940b; Livanov, 1940). Livanov (1940) found that rhythmic acoustical

stimuli produced cyclic changes in the activity over the auditory region

just as a flickering visual stimulus does over the occipital region.

Tactile, cutaneous, and pain stimuli (Berger, 1931, 1932b; Jasper and

Cruickshank, 1937; Travis and Barber, 1938; Livanov, 1940) and gusta-

tory stihiuli (Kitamura, 1939) have been found effective in blocking the

alpha rhythm, at least in their respective cortical areas. Lovell, et al.

(1939) have reported various modifications of the EEG in response to

vestibular stimulation. Not only do sensory stimuli modify or block

the spontaneous rhythms of the cortex, but in some instances they actu-

33] ELECTROENCEPHALOGRAPHY 1057

ally initiate responses, called evoked potentials, with on and off effects.

These have been noted for visual stimulation by Jasper (1936b) and

Cruickshank (1937) and for auditory stimulation by P. A. Davis (1939).

H. Davis, et al. (1939a) have noted a multi-phasic response to auditory

stimulation during sleep, which they call a "/^-complex."

ATTENTION AND "MENTAL SET." Berger (1930, 1932b, 1938c) con-

sistently held to the view that anything which distracted a subject, or

tended to focus attention upon a stimulus or a task blocked the alpha

rhythm. He interpreted blocking as an inhibitory phenomenon (after

Pavlov). Changes in the EEC with attention were in accord, he thought,

with the idea that perception may take place through only one sensory

channel at a time. Thus energy might be directed into the part of the

brain which is active, but the rest of the brain is temporarily inhibited

(1930, 1931). The influence of states of attentiveness, or readiness to

respond, induced by means of preparatory signals or instructions, was

investigated by A. C. Williams (1939, 1940). He found evidence of

facilitation of the alpha rhythm in the form of bursts of increased activity

during these states. The mobilization of attention or effort directed

toward a single task such as silent or oral reading, according to Knott

(1938b) reduces the amplitude of the alpha waves. Given an appropriate

"mental set" by preliminary instructions to respond to certain stimuli in

certain ways led to reduction of blocking time (Knott, 1939). Knott

believes that some peripherally maintained process such as afferent im-

pulses from kinesthetic sources alters the electrocortical conditions asso-

ciated with "mental set." A similar view is held by Freeman (1940),

who attempted to show that a "postural substrate" or peripheral excita-

tion level, represented principally by proprioceptive and imeroceptive im-

pulses, determines central excitatory tendencies and governs the autono-

mous rhythms of the brain. Hadley (1940, 1941), proceeding on the

basis of this hypothesis, studied cortical and peripheral activity during

rest and mental work, but concluded that there were no consistent rela-

tionships betwen skeletal muscle or heart activity and the EEG.

It cannot be denied, however, that relaxation and mental repose favor

the development of stronger and more persistent spontaneous rhythms of

the brain. Many workers have noted that an apprehensive or physically

tense subject at the very beginning of a period of study produces an EEG

which is not entirely typical of the pattern of activity the EEG may

show after the initial tension has been dissipated. Whether the cortical

activity is dependent upon the peripheral state or vice versa is not known.

There is also a possibility that both are determined by discharges from

subcortical centers, especially those from the diencephalic region which

may be associated with emotional states.

MENTAL WORK AND EFFORT. It is well known that answering ques-

tions involving mental effort or doing problems in mental arithmetic

blocks the alpha rhythm and otherwise modifies the EEG (Berger, 1930,

1932b, 1938c; Gibbs, et a/., 1935; Rohracher, 1935, 1937a, 1937b.

1058 PERSONALITY AND THE BEHAVIOR DISORDERS [33

1937c; Liberson, 1937; and others). Again, however, it is not known

whether these are direct results of cortical activity or are secondary to

emotional or affective states created by the situation. Berger (1933a)

notes that alpha production during mental work is variable and sporadic,

which he interprets as evidence of fluctuation of attention and concen-

tration. Berger (1938c) found a predominance of fast beta waves of 40

to 100 per second during mental work. Rohracher (1937b) and Gemelli

(1937) described very high frequency activity (1,000 to 2,000 per sec-

ond) during mental effort. As previously mentioned, frequencies of this

order are probably from some extraneous source, rather than from the

brain. In fact there is a possibility that the so-called beta wave activity

observed by Berger was at least partially due to muscular tension which

is frequently associated with mental effort.

Travis (1937) reported on what he called "the temporal course of

consciousness." Occipital EEC's were recorded in eight subjects while

lying in a dark room and allowing their "mind to wander/' They were

interrupted at various times by the word "Now" at which time they

were to give an introspective report of what stream of thought was in-

terrupted. When changes in the EEG were correlated with the subject's

report of the content of consciousness, it was found that visual images,

kinesthetic sensations, and mental effort were associated with relatively

small brain potentials while mental blankness and abstract thinking were

associated with relatively large potentials. A few reports suggested that

verbal ideas and anxiety were associated mainly with small waves, usually

more rapid than normal 10 per second alpha waves. It was concluded

that large, regular brain waves indicate a state of cortical equilibrium

represented by general psychic activity, while a dissolution of this col-

lective action into more rapid and irregular waves of lower amplitude

represents a high degree of specificity in psychic activity.

THE EEG IN RELATION TO EMOTIONAL AND AUTOMATIC FACTORS.

Berger (1933a) has reported that fright abolishes the alpha rhythm.

The unexpected explosion of a firecracker caused in one subject an

abolition of alpha waves for 17 seconds, with sporadic appearance and

disappearance of the waves for a longer interval. He noted also that

after fright the alpha waves may speed up to almost double the original

frequency. He states that fear and anxiety are apt to produce more rapid

alpha waves than normal. Jasper and Andrews (1938a) also observed

that "startle" might block the alpha rhythm for IS to 20 seconds; beta

waves were blocked only momentarily. Loomis, et al. (1936b) and

A. C. Williams (1939) observed that embarrassment and apprehension

practically abolish the alpha waves. By imagining a terrifying situation

some subjects could produce a phantasy of fear by which they could stop

the alpha waves almost at will.

Obermann (1939) investigated affective states aroused in 33 subjects

by artificial lying situations. Lie records were detected with consider-

ably better than chance success by five experienced judges who noted

33] ELECTROENCEPHALOGRAPHY 1059

certain general alterations of the alpha rhythm when key words asso-

ciated with the guilt situation were presented. Jost (1941) studied a

variety of autonomic measures and the EEG in 18 emotionally un-

stable children and 20 stable children during a number of conditions,

including frustration. He found a greater dominance of the alpha rhythm

(i.e., a higher alpha index) among the stable group following frustra-

tion. In general, the unstable group was characterized by more pro-

nounced physiological changes. He concludes that emotionality may be

measured by the dominance of the alpha rhythm. The greater suppres-

sion of the alpha rhythm in the unstable group with the greater autonomic

reactions, suggests to him that interoceptive stimulation, like exterocep-

tive, may inhibit or reduce the amount of alpha rhythm in individuals

chronically disturbed emotionally. A similar study was conducted by

Sherman and Jost (1942) with 10 adults and 48 children during frus-

tration experiments. They concluded that despite variations, the EEG

and autonomic measures provided a better index of emotional reactivity

than did overt behavior or the evaluation of verbal production.

Hoagland, et al. (1938a) studied heart rate and the EEG in normals

and a group of 25 psychotics during emotional probing with questions

related to significant events in the individual's history. Both normals

and psychotics showed increases in heart-rate and in delta index (the

amount of slow wave activity) measures following strong emotional

stimulation, but differential effects in the two measures were noted.

Increased delta activity was said to be more closely related to subjective

aspects of emotion. With the repetition of an emotionally charged ques-

tion the delta index decreased. Although the authors dispense with the

possibility that the effects noted may have been due to skin resistance

changes, they neglect the more probable possibility that the delta wave

changes may be associated with skin potentials. They did, however, find

that greater potential changes occurred over the motor regions than

over the occipital area; this differential response, if sufficiently clear,

would favor a cortical rather than a skin origin of their effect.

In another study Hoagland, et al (1938b), recording simultaneously

from leads over the occipital area of the cortex and from a "hypothala-

mic" lead placed far back in the nasal pharynx at the base of the brain,

observed similar though not identical activity in the two regions. For a

short period immediately following emotional stimulation by probing

with significant questions, delta activity was increased in both regions.

The delta waves in both records were roughly synchronized, but those

from the "hypothalamic" region showed slight precedence. It was con-

cluded that the delta waves probably originate in the hypothalamus and

are reflected in the cortical records as a conscious correlate of emotional

response.

The EEG and various autonomic measures were studied in 10 indi-

viduals in response to emotional stimulation (unspecified) by Darrow,

et al. (1942). It was reported that beta waves increase and alpha waves

decrease following stimulation. They infer from the EEG and the rela-

io6o PERSONALITY AND THE BEHAVIOR DISORDERS [33

tionships among the autonomic measures that there are two principal

effects following stimulation, one, the effect of excitation processes and

two, the homeostatic effects of a rise in blood pressure. These results are

interpreted as indicating that alpha wave production is associated with

vasoconstrictor tone.

Jurgens (1940), using a number of autonomic measures and the EEC,

studied the effects of deep breathing, fear, cold, and pain. Stimuli hav-

ing psychic meaning (presumably emotionally toned) produce both gal-

vanic skin and vasomotor responses, whereas neutral stimuli produce

only the latter. Inhibition of the alpha rhythm was most marked fol-

lowing stimuli which produced the greatest effect on vegetative functions.

All strong stimuli which produce pain and psychic excitement are of this

type.

In a man with voluntary control of the pilomotors, Lindsley and

Sassaman (1938) found a generalized sympathetic response. Associated

with this were localized slow wave discharges over the premotor regions

of the brain only. These were interpreted as cortical components of the

autonomic discharge, but were accompanied by no special emotional

state.

HYPNOSIS AND TRANCE STATES. Loomis, et al. (1936a, 1936b),

studied a subject before and during hypnosis. The EEG was entirely

normal originally and did not change during hypnosis. The EEG during

hypnosis showed none of the characteristics found in the EEG during

sleep. Therefore, it is said that the term "hypnotic sleep" is not appli-

cable according to this criterion. During the hypnotic state the subject,

with eyes open in a lighted room, was told that he could see nothing and

alpha waves appeared in the record ; when told he could see the waves

disappeared. Thus by suggestion it was possible to make the waves

appear and disappear; this was true whether the room was lighted or

was dark. The abolition of the waves was almost immediate on being

told he could see, but there was a delay of 4 or S seconds before the

waves reappeared when told he could not see. After the suggestion that

he could feel nothing, a pin was thrust through the skin of the subject ;

the alpha waves blocked for a short time but there was no evidence that

pain was felt.

Blake and Gerard (1937) induced a cataleptic state but not a fully

somnambulistic state of hypnosis in a subject and found that the alpha

rhythms normally present persisted, but with slight reduction in ampli-

tude. A 14 per second rhythm, typical of the initial stages of sleep, was

noted at times, but none of the slow waves characteristic of deep sleep

were found during the period of hypnosis. Whether the eyes were open

or closed, the alpha waves could be abolished by suggesting that a light

was shining in the eyes of the subject, despite the fact that no light

stimulus was present. The reverse suggestion, that the subject could see

no light, when a light was present, did not succeed as the waves were

33] ELECTROENCEPHALOGRAPHY 1061

abolished. In this latter respect their results differ from those of Loomis

and collaborators.

Marinesco, et al. (1937b) made observations of a subject who could

fall into such a profound state of sleep that he did not awaken when

needles were inserted through the scalp. His EEG showed periods of

normal alpha waves interspersed with periods of 1 or 2 seconds in

duration when no alpha waves were present. During "hypnotic sleep"

they observed at first an augmentation of frequency and voltage, but

later a reduction in both.

Thomson, et al. (1937) studied an individual who was subject to

migraine headaches and who was able voluntarily to induce light trance

states in himself. Memory for events during the trance state frequently

was absent. During a trance he sat completely relaxed with his head back

against a chair and asked and answered questions as three or four dif-

ferent assumed personalities. Drowsiness was common for an hour or

more preceding a trance state and the EEG immediately before, during

a brief period of dozing, was characteristic of light sleep. During the

trance state the alpha index approximated 100%, whereas before or

after the trance it ranged from 10 to 50%. They interpret the trance

state as one of light sleep.

INTELLIGENCE AND THE EEG. Relatively little investigation of the

relationship between intelligence and the EEG has been carried out with

populations of normal subjects. Considerable work has been done in

connection with mental deficiency, the results of which will appear farther

on. Lindsley (1938a), correlating frequency of occipital alpha waves,

per-cent-time alpha, and pattern of waves with intelligence (Stanford-

Binet and Otis tests) in 88 normal children of ten to fourteen years of

age, found no significant relationships. Knott, et al. (1942) found a

correlation of .50 between occipital alpha frequency and intelligence

(Stanford-Binet Revision) for a group of 48 eight-year-olds. The rela-

tionship between alpha index and intelligence for the same group was

not significant and neither were correlations between occipital or pre-

central alpha frequency and intelligence for another group of 42 twelve-

year-olds.

From the preceding results it appears doubtful that there is any very

high degree of relationship between intelligence as measured by tests and

the EEG ; the results in the area of mental deficiency in general confirm

this. Although the correlation obtained between intelligence and occipital

alpha frequency by Knott and collaborators for a group of eight-year-olds

is statistically significant it still does not express a very high degree of

relationship. The surprising thing is that it is as high as they found, for

in a single age group such as they used in order to partial out the effect

of a third variable, chronological age, the dispersion of alpha frequencies

is limited to about 3 cycles per second [Lindsley (1938a) found the

range of frequencies for eight-year-olds to be 7.3 to 10.3 per second].

1062 PERSONALITY AND THE BEHAVIOR DISORDERS [33

Interindividual differences in frequency do not therefore stand in a very

high ratio to intraindividual variations which probably range from zero

to 1 or more cycles per second from day to day. This would seem to pre-

clude high correlations within a single age group.

A wider dispersion of frequencies could be obtained by including

other age groups, especially lower ones, but this brings other factors into

the picture. The most important of these is the fact that curves of alpha

frequency growth and mental growth are both functions of age. Alpha

frequency is a logarithmic function of age, whereas mental growth, meas-

ured by an age-scale such as the Stanford-Binet, is arbitrarily made a

linear function, with a slope of 1 for the average child. Add to these

difficulties of handling and interpreting the data, the variability of meas-

urement of intelligence, and the variety of physiological factors to be

described in the next section which influence the EEG, and the problem

of establishing a relationship between intelligence and the EEG becomes

quite complex, if not indeed meaningless.

Physiological Factors and the EEG. A variety of effects may be

produced in the EEG of a normal individual by modifications in the

physiological state of the organism. The changes in physiological state

may occur naturally as in sleep or may be produced experimentally. In-

dividuals vary in the amount of physiological stress or change that they

are able to undergo before showing behavior aberrations or variations

in the EEG. Differentiations of this kind among individuals are often

important to a better understanding of personality and behavior dis-

orders. A knowledge of the limits of physiological change which may

be tolerated is useful for classifying individuals according to the stability

of their reaction systems, for selecting individuals for certain tasks or

occupations, and for determining optimal environmental conditions. For

these purposes the EEG is frequently a more sensitive indicator than

external signs of behavior.

RESPIRATORY REQUIREMENTS. The effects of oxygen want on the

EEG were noted by Berger (1934b), who found that, except for a de-

crease in amplitude of the alpha waves, no marked change occurred until

consciousness became impaired. With loss of consciousness the EEG

changed suddenly and markedly, developing large slow waves of 1 to 2

per second. After one minute of normal oxygen supply, the slow waves

disappeared and consciousness returned. P. A. Davis, ct al (1938),

found that gas mixtures containing 8 to 11% oxygen produced first an

increase and then a decrease in amplitude of the alpha waves ; thereafter

there was a gradual induction of irregular and sporadic delta waves.

It was not until after 10 to 15 minutes of breathing of 8% oxygen, when

cyanosis was marked and consciousness impaired, that delta waves of

low frequency and high amplitude dominated the record. The delta

waves disappeared promptly upon restoration of oxygen, but the EEG

did not return to its original state until at least two minutes later.

Gibbs, et al. (1935) studied the effects on the EEG of breathing pure

33] ELECTROENCEPHALOGRAPHY 1063

nitrogen. First there was an increase in amplitude and a gradual slowing

of alpha waves. When the subject became extremely confused or un-

conscious large delta waves of 2 to 5 per second appeared. Similar

changes were noted when syncope was produced by tilting or by means

of sodium nitrite. Lindsley and Rubenstein (1937) found no significant

variation in frequency or amplitude of alpha waves in four normal sub-

jects during the breathing of pure oxygen, or during the breathing of a

10% oxygen mixture to approximate limits of toleration. Lyman, et al.

(1941) studied the effect of reduced atmospheric pressure (reduction of

partial pressure of oxygen) on the EEC. During "ascent" in a pressure

chamber an oxygen mask was worn. There was some reduction in the

amplitude, amount, and regularity of the alpha waves during the early

part of the "ascent/* but little change beyond 12,000 feet. The oxygen

mask was taken off for 10 minutes at 18,000 feet, but no marked changes

in the brain potentials were noted.

From the foregoing results it may be concluded that reduced oxygen

has no marked effect on the EEG until impairment of consciousness

occurs, at which time, or shortly before, the EEG shows a predominance

of delta waves. It is important to note, however, that F. A. Gibbs, et al.

(1942) found that unconsciousness induced in normal subjects by breath-

ing a mixture of 2% oxygen and 5% carbon dioxide was not associated

with high voltage delta waves. From the results of this and another

study (E. L. Gibbs, et al., 1942), involving determinations of carbon

dioxide in arterial and internal jugular blood, it was concluded that slow

waves associated with oxygen deficiency are not due to cerebral anoxia,

but rather are due to a lowered carbon dioxide tension in the brain.

The effects of voluntary hyperventilation or overbreathing, with con-

sequent reduction of carbon dioxide in the blood, are well known both

clinically and electrocncephalographically. In fact hyperventilation has

become a standard procedure for producing physiological stress during

the recording of the EEG. Deep, regular, and rapid breathing for sev-

eral minutes may produce dizziness and eventually unconsciousness in a

normal subject. However, before this happens there may be, even in the

records of otherwise normal individuals, some induction of abnormal

slow waves. Ordinarily normal persons do not show abnormal phe-

nomena within a period of 3 minutes of voluntary overbreathing, al-

though persons with epilepsy or even epileptic tendencies only, may

develop abnormal patterns of activity within less than 1 minute of hyper-

ventilation and in some instances seizures may occur.

Thus hyperventilation is useful for detecting evidence of physiological

instability or inadequacy of homeostasis and in certain disorders, epilepsy

particularly, it may elicit latent signs of abnormality in the EEG. Gibbs,

ct al. (1935) described the effect of hyperventilation in producing delta

waves in the EEG and in precipitating seizures in epileptics. Davis and

Wallace (1942), studying normal subjects, found that delta waves were

less easily induced when the respired air contained oxygen in excess of

the normal 20%, and also when glucose was administered before hyper-

1064 PERSONALITY AND THE BEHAVIOR DISORDERS [33

ventilation. They concluded that hyperventilation facilitates delta wave

production by causing cerebral vasoconstriction, which in turn dimin-

ishes the supply of oxygen and dextrose available to the brain. E. L.

Gibbs, et al. (1942) have presented evidence which favors another ex-

planation. The analysis of arterial and internal jugular blood for oxygen

and carbon dioxide content at intervals during the recording of the EEG

revealed evidence which suggested to them that the principal cause of

delta wave development in some individuals during hyperventilation is

a failure of homeostatic mechanisms to preserve carbon dioxide tension

in the brain. Their evidence seems to indicate that in such individuals

there is insufficient cerebral vasoconstriction to compensate for the reduc-

tion in carbon dioxide during hyperventilation.

Liberson and Strauss (1941) found that delta wave activity during

hyperventilation diminishes with increasing age, being most marked in

children below fifteen years of age. This has been confirmed by Brill

and Seidemann (1942), who also noted that delta wave discharges dur-

ing hyperventilation occur among normal and nonepileptic subjects and

are not therefore pathognomonic for epilepsy. The latter investigators

suggest that an abnormal response to hyperventilation may occur in

normal brain tissue when there is a disturbance in the regulatory mech-

anism for carbon dioxide in the blood, or may arise from damaged brain

tissue abnormally responsive to normal shifts of carbon dioxide level.

Colin and Katzenelbogen (1939) report that in deep sea diving the

replacement of nitrogen with helium tends to produce a sedative action.

They compared EEC's recorded during the breathing of normal air and

a helium-oxygen mixture and found that the latter increased the amount

of alpha activity present. They suggest that helium may help to maintain

an optimum oxygen supply to the cortex.

HYPO- AND HYPERGLYCEMIA. Reduction of the blood sugar level

below a critical limit will produce coma and unconsciousness, but before

this stage is reached there is a slowing of the alpha rhythm and sporadic

slow wave components may appear in the EEG (Berger, 1937d; Hoag-

land, et al., 1937a, 1937b; Marinesco, et al., 1938; F. A. Gibbs, et al.,

1939, 1940 ; Himwich, et al., 1939a, 1939b; P. A. Davis, 1941c). During

coma, continuous large slow waves predominate. Slight hypoglycemia

may significantly affect results during hyperventilation (Davis and Wal-

lace, 1942; Rubin and Turner, 1942). High concentrations of blood

sugar tend to shift the energy in the cortical frequency spectrum toward

the higher frequencies (F. A. Gibbs, et al., 1940).

ACID-BASE BALANCE. Changes in the pH of the blood beyond cer-

tain limits have been reported by Lennox, et al. (1938) and F. A. Gibbs,

et al. (1940), to slow the electrical activity of the cortex with a shift

toward alkalinity and to speed up activity with a shift toward acidity.

TEMPERATURE. Hoagland (1936b, 1936c, 1936d) has demonstrated

that the elevation of body temperature in human subjects by diathermy

33 ] ELECTROENCEPHALOGR APH Y 1065

treatment increases the frequency of the alpha waves. This has been con-

firmed also by Jasper (1936a). Hoagland believed that the frequency

of the rhythm was directly related to metabolic processes and that the

increased frequency with temperature elevation was a reflection of the

increase in velocity of underlying chemical events.

METABOLISM. Frequency of the alpha rhythm has been found to be

related to metabolism in normal subjects (Lindsley and Rubenstein,

1937) and in patients with thyroid disorders (Ross and Schwab, 1939).

Artificial elevation of metabolism by means of thyroid extract has been

shown to increase the frequency of the alpha waves (Gerard, 1936;

Lindsley and Rubenstein, 1937 ; Rubin, et al. y 1937). There is an obvious

difficulty in attempting to correlate metabolism with the EEC, since the

former is representative of the activities of the organism as a whole

whereas the latter represents only a part of that whole. No doubt if

metabolism of a part of the living brain could be determined at the same

time that the electrical activity was recorded from that part a much closer

correspondence would be revealed. Th fact that temperature, blood

sugar level, acid-base balance, oxygen < jnsumption, and other physio-

logical variables are known to produce /ariations in the EEG is strong

evidence that characteristics of the EEG are in part controlled by

metabolic factors.

DRUGS AND ANESTHETICS. A number of drugs, if administered in

sufficient quantity, have been found to modify the pattern and character-

istics of the EEG. However, little is known as yet about the locus of

action of the drugs and in many cases it is not clear whether or not the

modifications of the EEG produced in this way are secondary to other

physiological changes produced by the drugs. In some instances it is

possible that a particular drug directly affects the electrical output of

cortical cells, whereas in others the effect may be principally upon

thalamic or other subcortical centers and thus produce changes in the

EEG by modifying cortical and subcortical interrelationships. The block-

ing of the influx of centripetal impulses from peripheral sources at the

thalamic level is no doubt responsible for many of the changes which

may be produced in the EEG. A further complication is the fact that

some drugs, though depressant in moderate or large doses, have excitant

properties in small dosages or in the early stages of the effect.

Only a cursory review of the effects of drugs and anesthetics on the

EEG can be given here. Further discussion of the therapeutic use of

drugs and their effects on the EEG will be brought out later.

There is a tendency for all anesthetic drugs, given in sufficient amount

to induce a state of surgical anesthesia, to produce changes in the EEG

similar to those of deep sleep, namely, continuous large slow waves of

about 1 or 2 per second. During the initial excitant and subsequent early

depressant phases the chief differential effects on the EEG by the dif-

ferent anesthetics are apparent. Volatile, fat solvent anesthetics such

as chloroform and ether (Berger, 1931, 1932b; F. A. Gibbs, et al,

1066 PERSONALITY AND THE BEHAVIOR DISORDERS [33

1937a) show initially an increase in size of alpha waves followed by a

diminution in frequency, amplitude, and amount of alpha waves, and

an increase in the amount of beta activity; ultimately alpha waves dis-

appear and are replaced by slow delta waves. Anesthetic gases such as

nitrous oxide (van der Molen, 1938), and cyclopropane (Rubin and

Freeman, 1940, 1941) show initially an increase in amplitude of alpha

waves and a gradual diminution of frequency and amount ; later during

deepening anesthesia alpha waves are replaced almost entirely by slow

waves of 3 per second or less. During recovery from cyclopropane the

pattern of the EEC is more varied and shows considerable shifting from

slow to fast frequencies. Barbiturates such as evipan (Berger, 1934a),

or evipal (F. A. Gibbs, et al., 1937a), phenobarbital (F. A. Gibbs, et al.,

1937a; Cutts and Jasper, 1939; Lindsley and Henry, 1942), and sodium

amytal (Hughes, et al., 1938; Fowler, 1941; Rubin, et al., 1942; Cohn

and Katzenelbogen, 1942) are more differential in their effects on the

EEG than other anesthetics and differ among themselves, although there

is a distinct tendency for all barbiturates in general to produce prominent

fast frequency components in the EEG. This property has been noted

most clearly and most consistently for sodium amytal. In the author's

experience (unpublished observations) the extremely rhythmic, almost

sinusoidal, fast waves of IS to 20 per second, appearing and disappearing

at different intervals of time and in different regions of the head, con-

stitute the outstanding feature of the sodium amytal EEG. Alkaloids

such as scopolamine (Berger, 1931; F. A. Gibbs, et al., 1937a), mor-

phine (Berger, 1931, 1937e; F. A. Gibbs, et al., 1937a) ; cocaine (Berger,

1937d; Fowler, 1941; Rubin, et al, 1942), atropine (Berger, 1937d;

F. A. Gibbs, et al., 1937a) ; caffeine (F. A. Gibbs, et al., 1937a; Griittner

and Bonkalo, 1940b; Fowler, 1941), and mescaline (Chweitzer, et al.,

1937a, 1937b; Rubin, et al., 1942), depending upon dosage, produce

varied changes in the EEG, consisting of modification of the frequency,

amplitude, and amount of the alpha rhythm. With larger doses, these

drugs tend to increase the amount of beta activity also. The alpha wave

changes are not always consistent from one drug to another, although

during the initial excitatory phases of each there is a tendency for ac-

centuation of the alpha waves ; subsequently the amount of alpha activity

is reduced and there is a tendency to burst-like discharges of alpha

waves with intervening beta waves, especially for scopolamine, morphine,

and mescaline.

Fowler (1941) and Rubin, et al. (1942), have noted in connection

with sodium amytal, mescaline, and cocaine that changes in the EEG

were accompanied by definite psychological changes in behavior and per-

sonality. The latter emphasize that the psychological changes are of two

types, those characteristic of a particular drug and those characteristic

of the individual, including his personality and behavior disorder or

psychosis.

Andrews (1941) made an extensive study of morphine addicts and

found that while receiving the drug they show a higher alpha wave output

33 ] ELECTROENCEPHALOGRAPHY 1067

(per cent time alpha) than normals or than addicts who have not had the

drug for a year or more. In addicts, during and after withdrawal of the

drug the high alpha output may persist for a considerable period of time

or may drop suddenly, in spite of the fact that during progressive with-

drawal there is a high degree of "emotional tension" present, a factor

which frequently greatly diminishes alpha output. In general a single

dose in a nonaddict had little effect on the EEG.

Autonomic drugs such as adrenalin (F. A. Gibbs, et a/., 1937a;

Fowler, 1941), mecholyl (Fowler, 1941), atropine (F. A. Gibbs, et al.,

1937a), ergot (F. A. Gibbs, et al., 1937a), benzedrine (F. A. Gibbs, et

al., 1937a; Cutts and Jasper, 1939; Lindsley and Henry, 1942; Rubin,

et al., 1942), and others, given in the usual clinical dosages, have not

produced marked or consistent changes in the EEG, despite the fact that

in some instances behavior may have been definitely altered.

Hoagland, et al. (1939), found that dinitrophenol, a respiratory and

metabolic stimulant, increased the frequency of the alpha waves. Rubin

and Freeman (1938) observed that cyanide, a respiratory stimulant, in-

creased the amplitude, amount, and regularity of the alpha rhythm in

schizophrenic patients. Convulsant drugs such as cardiazol or metrazol

produce striking changes in the EEG associated with convulsions ; the

EEG changes resemble those seen in actual convulsive seizures and will

be discussed further in connection with shock therapy.

Loomis, et al. (1936b), noted that alcohol increased the amplitude

and decreased the frequency of the alpha rhythm ; during the early stages

of alcoholic sleep the alpha rhythm persisted and in this respect the EEG

was unlike that of sleep. F. A. Gibbs, et al. (1937a), found that alcoholic

intoxication caused slowing and a reduction of the alpha rhythm, with

some increase in beta activity and slow waves. A more extensive study

of the effects of alcohol on the EEG was made by P. A. Davis, et al.

(1941), who found a slowing and a reduction of the alpha rhythm dur-

ing low concentrations of blood alcohol ; but with higher concentrations

(125 to 140 mg. per 100 cc.), episodes of 4 to 8 per second slow waves

appeared and were associated with clinical signs of slurring of speech,

ataxia, emotional changes, and poor performance on psychometric

tests.

The EEG seems to be a fairly sensitive indicator of modifications of

central nervous system activity induced by certain drugs and there is a

definite need for careful and systematic study of such changes in relation

to varying amounts of drugs. This information should provide a better

understanding of the effects and locus of action of drugs, and in some

instances the EEG, in combination with clinical observations of behavior,

should be useful in determining the optimal dosage of medication.

FATIGUE. Gruttner and Bonkalo (1940b) have observed that the

EEG of normal persons during fatigued states shows irregularity, slow-

ing, and reduction of the alpha rhythm with some tendency to random

slow waves. Pervitin (l-Phenyl-2-methylaminopropans) and caffeine,

io68 PERSONALITY AND THE BEHAVIOR DISORDERS [33

after 20 to 30 minutes, alleviated the feeling of fatigue, but only caffeine

tended to return the EEC to its normal state.

SLEEP. The EEC undergoes striking changes during the process of

going to sleep. Berger (1932b) noted that there was a marked reduction

in the alpha waves. Loomis, et al. (193Sa, 1935b, 1936a, 1936b), study-

ing all-night sleep records, observed the gradual reduction of the alpha

rhythm during the drowsy phase of going to sleep and called attention

to a variety of new wave forms and patterns appearing with the onset

of sleep, emphasizing particularly the development of 12 to 15 per second

spindle formations and the appearance of random slow waves. From

the work of several groups of investigators (Loomis, et al., 1937, 1938;

Blake and Gerard, 1937; Klaue, 1937; Harvey, et al., 1937; Davis, et al.,

1937, 1938; Marinesco, et al., 1937b, 1937c; Blake, et al., 1939; Miiller,

1939; Griittner and Bonkalo, 1940a) there has emerged a fairly con-

sistent and systematic picture of the changes of the EEG during various

stages of sleep. Briefly, these stages may be characterized as follows :

(1) relaxed and resting, but awake normal alpha rhythm at start, but

with occasional interruptions and diminution of amplitude toward end of

stage; (2) distinctly drowsy and beginning of light sleep alpha rhythm

drops out and low voltage slow waves of 4 to 5 per second appear ;

(3) real sleep spindle-shaped volleys of 14 per second waves appear,

and slow waves increase in magnitude and decrease in frequency ;

(4) deeper sleep spindle formations become more prominent and slow

waves become larger, slower, and more continuous ; ( 5 ) very deep sleep

spindles disappear, slow waves become very large and very slow (less

than 1 per second and up to 500 microvolts) and more irregular.

During the process of going to sleep there is some tendency for the

patterns of the EEG to fluctuate from one stage to another in the A, B,

and C stages ; the "onset of sleep" probably occurs at the end of the B

stage. When the alpha waves disappear during the B stage, awareness

of external stimulation is lost or greatly depressed. Dreams occur chiefly

during the B and C stages, but are seldom recalled if alpha waves have

been completely absent for some time. The transition from sleep to wake-

fulness follows a similar, though more variable, course. With return of

consciousness on waking, alpha waves are present, but continue to be of

low voltage for some time (Blake, et al., 1939) ; hence EEG patterns for

different individuals on waking tend to be more homogeneous (Henry,

1941a). Movement of the individual, or stimulation during sleep fre-

quently causes the EEG pattern to revert temporarily to an earlier or

lighter stage of sleep.

The Electroencephalogram in Neurologic Disorders. Clinical ap-

plication of the EEG began early with the work of Berger. Its usefulness

as an adjunct to the clinical, neurologic examination soon became evident,

first, in connection with epilepsy and related disorders and subsequently

in the discrimination and localization of brain tumors and other types of

brain pathology. Not only has the EEG proved useful as a supple-

33 1 ELECTROENCEPHALOGRAPHY 1069

mentary tool for the neurologist and neurosurgeon, but it has brought

forth information which has provoked new conceptions of brain function

and new ways of envisaging brain disorders.

EPILEPSY AND RELATED DISORDERS. During an epileptic attack, or

even in the intervals between attacks, the EEG may show unusual pat-

terns of electrical activity consisting of paroxysmal outbursts of waves of

abnormal frequency and voltage. Some of the patterns are composed of

wave-complexes so unique that they practically constitute a signature for

certain types of epileptic disturbances. However, the trend of results of

recent studies shows that there may be considerable overlapping of

patterns and wave forms among the so-called "epilepsies," and that some

of the variations associated with epilepsy may also be found to some

extent in certain nonepileptic conditions. Despite this fact, the EEG has

proved to be of exceptional value in the diagnosis, experimental study

and treatment of epilepsy (see Chapter 31 by Lennox).

Berger (1931, 1932c, 1933b, 1934b, 1935b) was the first to study

epileptic states in human subjects by means of the EEG. He noted that

the EEG was unusually flat during the epileptic stupor following an

attack and that during an "absence" the alpha waves dropped out and

were replaced by high amplitude beta waves. He also observed that large

3 per second waves were associated with the rhythmic convulsive move-

ments of a seizure. However, Berger found it difficult to record the

EEG satisfactorily during seizures and was unable to give a very sys-

tematic description of the electrical events which occur during seizures.

F. A. Gibbs, et at. (1935, 1936) were the first to obtain satisfactory

records during seizures and to differentially classify the EEG patterns

during petit mal and grand mal attacks. During petit mal seizures they

observed large, smooth contoured, 3 per second waves or wave and spike

formations of about 3 per second. The latter pattern was considered

pathognomonic for petit mal epilepsy by Gibbs and Lennox (1937).

Between seizures they frequently found the EEG normal except for

occasional, brief groups of waves of a pattern similar to that during a

seizure state, but of lower amplitude and less persistent. They called

these low amplitude outbursts "larval seizures" since they seemed to be

composed of the same elements as the electrical discharge during an

actual attack. Later this type of activity became known as a subclinical

seizure since there were no clinical manifestations associated with the

electrical outbursts. During grand mal attacks there was a gradual build-

ing up of high amplitude fast waves of about 15 to 25 per second.

Shortly after this discharge began, tonic contractions appeared; as the

seizure progressed and clonic contractions began, slow waves mixed

with fast waves appeared. During the relaxation phase following the

cessation of convulsive activity, the EEG was abnormally flat and only

slowly returned to its initial state as the patient regained consciousness.

After recording EEC's during seizures in a large number of epilep-

tics of different types, F, A. Gibbs, et al (1937b, 1938a), concluded that

1070 PERSONALITY AND THE BEHAVIOR DISORDERS [33

epilepsy can best be defined, in terms of electrocortical events represented

in the EEC, as a paroxysmal cerebral dysrhythmia. They described three

types of EEC's corresponding to different types of seizure patterns and

later (Gibbs, et al., 1939) added a fourth. These four general types of

seizure patterns are illustrated in Figure 3, but it should be emphasized

that there are many additional variations of the EEC in epilepsy. Ac-

cording to these authors the EEC during petit mal attacks is character-

ized by a wave and spike formation which is commonly most prominent

in the frontal and precentral regions. Grand mal attacks are associated

with a crescendo burst of fast waves starting from low amplitude and

gradually building up during the tonic phase to high voltage waves which

fuse into 3 to 6 per second waves as the clonic phase begins. This type

of activity frequently originates in the frontal and precentral regions also.

Psychomotor or psychic equivalent attacks, consisting of apparently con-

scious acts of impulsive, uncontrolled character, are accompanied by a

building up in voltage of 3 to 6 per second waves, often with squared

tops. This pattern frequently develops into high voltage 6 per second

waves and is most commonly observed over post-central and occipital

regions. In the petit mal variant attack there is usually no clonic activity

as in petit mal and the EEC pattern consists of a slow wave and spike of

about 2 per second or less rather than the typical 3 per second pattern

of petit mal.

A somewhat different emphasis in the classification of EEC patterns

in epilepsy has been proposed by Jasper and Kershman (1941), and

Jasper (1941). Studying a group of 494 epileptics, principally during

the intervals between attacks, they found that definite abnormalities of

a paroxysmal character were present in the EEC's of 95% of the patients.

They emphasized two abnormal features of the EEC's of epileptics,

hypersynchrony, or abnormal voltage, and dysrhythmia, or abnormal fre-

quency. The former, they believe, is the more important and they point

out that a seizure discharge in some cases may consist of a normal 10 per

second rhythm but of paroxysmally high voltage.

Jasper and Kershman report that localization or the distribution of

the disturbance provides the most satisfactory basis for classifying the

EEC's of epileptics. They describe three principal categories of dis-

turbance: localized unilateral, bilaterally synchronized, and diffuse.

About half of their cases showed discrete areas of localization of the

EEC disturbance in one hemisphere; 35% showed bilaterally syn-

chronous discharges, usually of bitemporal or bifrontal origin; and 15%

showed diffuse or widespread abnormalities. Another important aspect

of their classification system is the type of wave form and manner of

occurrence of the pattern of disturbance. Some patterns occur as random

disturbances whereas others appear as paroxysmal rhythmic sequences.

The former are represented as isolated single or multiple spikes, sharp

waves, and delta waves ; the latter appear in a variety of rhythmic forms,

including 3 per second waves, 3 per second wave and spike formations

and 6, 10, 14, and 25 per second waves.

33]

ELECTROENCEPHALOGRAPHY

1071

ro

CT

1072 PERSONALITY AND THE BEHAVIOR DISORDERS [33

Although Jasper and Kershman found some correspondence between

the pattern of the clinical seizure and the form of the EEG, as did Gibbs

and collaborators, they did not, however, find that the form of the

seizure could be accurately predicted from the form of the EEG disturb-

ance. They believe that the localization of the onset of the excessive elec-

trocortical discharge in a particular region of the brain and that area's

relations with other parts of the brain determine the form which the

clinical seizure will assume. As a consequence they do not favor the

application of clinical terminology for different types of seizure patterns

to the EEG abnormalities found in epileptics.

The electroencephalogram has opened up possibilities for the study of

a variety of factors associated with the nature, cause, and treatment of

epilepsy. Among some of these are the physiological and biochemical

aspects, the locus and origin of the attack, the prediction of attacks in

advance, the modification of seizure discharges by means of drugs and

so forth, and the hereditary factors.

Berger (1934b) and Gibbs, et al (1935), were the first to utilize

hyperventilation in conjunction with the recording of the EEG to bring

out latent signs of abnormality and epileptic tendencies. According to

Gibbs, et al. (1940), and Nims, et al. (1940), the importance of this pro-

cedure in the study of epileptics lies in the fact that mechanisms which

regulate the physicochemical state of the brain, especially in petit mal, are

so impaired that such persons are unable to adjust quickly to disturbances

of the acid-base equilibrium. Variations of other constituents of the blood

stream and the failure of homeostatic mechanisms (see Lennox, et al.,

1938) no doubt also facilitate, if not actually produce, predisposing tend-

encies to excessive electrocortical discharge. Like hyperventilation, stim-

ulation of the carotid sinus has been shown to be effective in some patients

in producing epileptic discharges and actual seizures (Romano, et al.,

1940; Margolin, et al., 1941).

Spontaneous variations in respiration resembling hyperventilation

have been observed by Cobb, et al. (1939), in petit mal patients preced-

ing an attack, as evidenced by the EEG. They suggest that changes in

respiration associated with emotional stress and hysterical episodes may

well be sufficient to produce seizure discharges in persons with a predis-

position to epilepsy. Schwab (1941) utilized the method of simultaneous

recording of respiration and the EEG to study the effectiveness of thera-

peutic procedures on the development of epileptic attacks.

The EEG is of value in localizing epileptogenic foci and in following

the spread of the disturbance from one region to another (Kornmuller,

1935a, 1935b; Gibbs, et al., 1937b; Golla, et al., 1937; Jasper and

Hawke, 1938; Janzen and Kornmuller, 1939b, 1940; Kornmuller and

Janzen, 1939a, 1941; Penfield and Jasper, 1940; Casamajor, et al.,

1941). Although foci of epileptic discharge may occur anywhere in the

brain the most common locus is in the frontal lobes, usually in the

neighborhood of area 6 aB of Vogt, a region which Foerster believed was

important in the origin and development of seizures.

33 j ELECTROENCEPHALOGRAPHY 1073

Jung (1939b, 1939d, 1939e) studied vegetative and EEC changes

simultaneously during many petit mal seizures. Although he found some

differential autonomic responses they were not striking and appeared to

be secondary to the seizure itself rather than a cause of the seizure dis-

charge. He found that muscle action potentials during clonic convulsions

followed the spike of the wave and spike formation by about 40 to 60

milliseconds. He observed that sensory stimulation, especially auditory

and pain, was effective in interrupting and inhibiting a seizure discharge

already under way. This has been observed also by Schwab (1941)

who found loud sounds more effective than light stimulation in termi-

nating a seizure discharge. Reaction time to stimulation during an attack-

was greatly prolonged, but variable, depending upon the magnitude and

duration of the seizure discharge.

Berger (1934b) believed that his findings in connection with the EEG

in epilepsy indicated that seizure phenomena were manifestations of de-

fective thalamic control of the cortex, with marked fluctuations of in-

hibitory influence giving rise to the pattern of seizure discharge. Korn-

muller and Janzen (1941) also emphasize the importance of subcortical

control, especially in petit mal seizures, since in some cases they found

clinical manifestations of the seizure prior to the onset of the electrocorti-

cal discharge and persistence of convulsions after cessation of abnormal-

ities in the EEG. The lack of a cortical focus of the EEG disturbance

was also interpreted as evidence of subcortical origin of seizures in some

patients. It has been reported (Gibbs, et a/., 1937b; Jasper, 1941), how-

ever, that removal of an area of focal discharge sometimes eliminates

further seizures as well as EEG abnormalities, but permanent relief is

not always assured.

In connection with the course and treatment of epilepsy in an indi-

vidual the EEG is of considerable value as an indicator of changing con-

dition as well as of optimal dosage of anticonvulsant therapy. In addition

to surgical intervention, Gibbs, et al. (1938a) point out that anticon-

vulsant drugs such as phenobarbital tend tc limit the spread of the elec-

trical discharge as well as disorganize and reduce it. Lennox (1940) has

discussed the value of drugs in the treatment of epilepsy. He states that

the ideal drug would be a regulator of the rate of the electrical rhythms

of the brain. Since the rate in grand mal is abnormally fast, in psycho-

motor seizures abnormally slow and in petit mal alternately fast and

slow, the commonly used anticonvulsants or sedatives, which tend to slow

the rate, are principally of value in the treatment of grand mal. On the

other hand, bromides and phenobarbital do have beneficial effects in some

petit mal cases; not apparently by suppressing the spike component

entirely but by a general reduction and disorganization of the pattern.

Lennox, et al. (1936), and Gibbs, et al. (1937b), found that pheno-

barbital and bromides increased the interval between seizures and re-

duced their intensity. Jasper and Nichols (1938) observed a decrease

in epileptiform activity in the EEG with luminal, sodium bromide or

ketogenic diet. They point out tha^ the EEG is valuable for following

1074 PERSONALITY AND THE BEHAVIOR DISORDERS [33

the course of treatment with anticonvulsants ; they also suggest that it

may indicate treatment for those who would not otherwise receive it due

to the lack of clinical seizures, but who have EEG evidence of con-

vulsive tendencies. In a group of children with frequent petit mal

attacks, Logan and Baldes (1942) found that a ketogenic diet resulted

in both clinical and electroencephalographic improvement. There was a

reduction in the number of seizures as well as a reduction of the amount

of epileptiform activity in the EEG.

Putnam and Merritt (1941) described a form of epileptic equivalent

state which they identified as dullness. The principal disturbance is one

of intellectual function and the attack may not be appreciated by the

patient or by those about him. The attacks are essentially brief

"absences" and may occur frequently. The best means of recognizing

such patients is by the EEG. Although there is no distinctive EEG

abnormality, the patient can frequently correlate brief intellectual lapses

with simultaneous EEG abnormalities. Putnam and Merritt found

dilantin an effective form of treatment in such cases.

One of the most interesting and at the same time important aspects

of the EEG has been its use in detecting hereditary evidences of epileptic

tendencies in relatives of epileptic patients. The incidence of abnormality

of epileptiform type in the EEC's of relatives (parents, siblings, and

children) of epileptics is as follows: Lennox, ct al. (1940), 60%;

Strauss, et al. (1939), 27%; Lowenbach (1939), 46%; and Robinson

(1940), 36%. Only the first two studies were based upon large num-

bers of subjects. Although there is considerable variation in the per-

centages, due probably to different criteria of abnormality and different

selections of relatives, there is general agreement of the results in show-

ing a significant hereditary component.

Lennox, ct al. (1939, 1940) recorded EEC's in 183 relatives of 94

epileptics and in 100 control subjects who had no near relatives with

epilepsy. Sixty per cent of the relatives as opposed to 10% of the con-

trol group had definitely abnormal EEC's. EEC's were obtained from

both parents in 55 families and in 35% records from both parents were

abnormal; in only 5% were the EEC's clearly normal. Similar evidence

comes from several other sources as was indicated above. The data of

Strauss, et al. (1939), were based on the EEC's of 93 relatives of 31

patients with a diagnosis of "idiopathic" epilepsy. They found some

families much more highly saturated with epileptiform activity than

others.

Lennox, ct al. (1940), and Gibbs (1940) believe the evidence indi-

cates that the dysrhythmia of epilepsy is inheritable and that when such

dysrhythmia is demonstrable it may represent a predisposition to epilepsy

or some related disorder. They feel that dysrhythmia may prove to be a

dominant trait since only 2.4% of near relatives of epileptics have clin-

ical evidence of epilepsy, whereas 60% have dysrhythmia. Strauss, et al.

(1939), raise the question of what significance epileptiform activity in

the EEC's of relatives of epileptics may have when they are free of

33? ELECTROENCEPHALOGRAPHY 1075

clinical evidence of seizures. They state that it may indicate a possibility

of subsequent development of overt seizures in young siblings, but they

feel that only a small number of the adult relatives with abnormalities

in the EEG will actually develop overt seizures. They also point out

the possibility of such relatives serving as "carriers" of epilepsy. Lowen-

bach (1939), after raising the question of whether the abnormalities of

the EEC's of relatives of epileptics are a symptom of epilepsy still not

severe enough to produce clinical evidence of convulsions, or are an

expression of a nonspecific functional instability of the central nervous

system, concludes in favor of the latter point of view.

Lennox, et at. (1939, 1940), studied 17 pairs of twins, one or both of

which had a history of epilepsy in the case of 15 pairs. Among these were

nine identical twin pairs; in two pairs both members had epilepsy and

abnormal EEC's and in seven other pairs both members had dys-

rhythmia but only one of each pair had seizures. In five or more of

these latter cases, the epileptic member had received an injury of the

brain prior to the onset of seizures. In one set of similar twins one

member had symptomatic epilepsy due to a head injury and the other

member had normal brain waves ; in another pair of similar twins one

had hysterical seizures and both members of the pair had normal EEC's.

Of four dissimilar twin pairs in which one member of each had epilepsy,

three of the normal members had normal EEC's. From these data the

authors conclude that epilepsy, the plant, is not inherited but that a

predisposition, the seed, is inherited in the form of cerebral dysrhythmia.

In a person with cerebral dysrhythmia, and thus a predisposition, actual

seizures may be facilitated by secondary factors such as brain injury,

toxic conditions and the like.

RELATED CONDITIONS. From time to time certain conditions such as

migraine, pyknolepsy, cataplexy, narcolepsy, and certain behavior dis-

orders of children have been likened to epilepsy. From the point of view

of the EEG, only pyknolepsy and some behavior disorders of children

show abnormalities similar to those of petit mal and psychomotor

epilepsy. Golla, et al. (1937), and Kornmiiller and Janzen (1941) have

found large amplitude 3 to 6 per second waves in children with pykno-

lepsy. A diffuse representation of abnormality is frequently present

with the most marked disturbance localized in the posterior head regions,

especially in the occipital areas. Golla and collaborators found these

patterns unaffected by luminal, but benzedrine abolished both the EEG

abnormalities and the seizures after a few days of treatment. Jasper and

Nichols (1938) and Jasper, et al. (1938), were the first to liken the

slow waves of the EEC's of behavior problem children to those of epi-

leptics and they pointed out that the behavior was also similar, inasmuch

as such children had what they called an "epileptoid" personality, char-

acterized by impulsive and variable behavior. The EEG in behavior

problem children will be described more fully elsewhere.

There is uniform agreement on the fact that the EEG presents no

1076 PERSONALITY AND THE BEHAVIOR DISORDERS [33

pathognomonic picture for narcolepsy (Gibbs, et al., 1935; Janzen,

1939; Blake, et al., 1939; Janzen and Behnsen, 1940; Dynes, 1941;

Dynes and Finley, 1941), During a narcoleptic attack the EEG shows

patterns of activity characteristic of physiologic sleep, although the stages

or normal sleep are somewhat foreshortened in the narcoleptic state.

Accordingly, from the point of view of the EEG, narcolepsy appears to

be a pathological extension of a normal physiologic mechanism. Likewise

there is no evidence that the EEG is characterized by any specific

abnormality during migraine headaches (Lemere, 1937).

BRAIN LESIONS. The EEG has been used extensively in the detec-

tion and localization of a variety of forms of brain lesions. For these

purposes it has proved to be an exceptionally useful adjunct to the usual

clinical neurologic examination and has become a distinct aid to the

neurosurgeon. In some cases where no obvious clinical signs of localiza-

tion are present the EEG may reveal evidences of pathology and thus

give direction to further search by clinical examination and X-ray meth-

ods, in other cases it has provided valuable confirmatory evidence of

localized pathology.

Brain tumors and abscesses are most readily detected when they

directly involve or impinge upon the cortex, although the EEG may

also reveal evidence of subcortical tumors by their indirect effect upon

the electrical activity of the cortex. Tumor tissue itself is not active

electrically (Foerster and Altenburger, 1935; Scarff and Rahm, 1941),

but the adjacent regions of brain tissue in process of invasion or other-

wise interfered with by toxic conditions, circulatory inadequacy, or

pressure effects give rise to a variety of abnormalities. These may take

the form of a reduction of the alpha rhythm as noted by Berger (1931,

1933b) or of large slow delta waves of less than 1 to 3 per second

(Walter, 1936, 1937). Walter called the concentration of such waves of

increased amplitude over the area of the tumor a "delta wave focus."

The focus of a tumor may be more precisely determined by phase

reversal and triangulation methods. In addition to the large random or

rhythmic slow waves, Case and Bucy (1938) have noted that there may

be isolated spikes and "saw-tooth" wave forms arising from the region

of a tumor or other pathological process. Frequently a tumor or other

pathology may be detected by the bilateral differences in the electrical

activity on the two sides of the head (Kornmuller, 1904b). Figure 4

illustrates the localization of a tumor by means of the EEG.

A number of techniques and methods of localization have been

described (Kornmuller, 1938, 1939, 1940a, 1940b, 1940c; Kornmuller

and Janzen, 1939a, 1939b; Williams and Gibbs, 1938a, I938b, 1939;

Gibbs, Munro, and Wegner, 1941 ; and others). The accuracy of local-

ization, particularly for tumors involving the cortex, has been shown to

compare very favorably with other more time consuming or more

rigorous methods, including the neurologic examination, pnuemoen-

cephalography and ventriculography (Yeager, et al., 1940; Gibbs,

33]

ELECTROENCEPHALOGRAPHY

1077

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1078 PERSONALITY AND THE BEHAVIOR DISORDERS [33

Munro, and Wegner, 1941). The diagnostic and surgical value of the

EEC has been widely discussed (Marinesco, et al, 1937a, 1938a; Tor-

rents, 1940; Sarkisov and Pentsik, 1939; Williams and Gibbs, 1938a,

1938b, 1939; Walter, 1940a, 1940b; McDonald and Korb, 1940a, 1940b;

and others), and in general with very favorable conclusions. However,

it should be made clear that the EEG examination is a supplement to,

rather than a substitute for, the clinical neurological examination or

X-ray procedures. Its principal value lies in any additional information

it may reveal in certain cases and in the direction it may give to the

search for neurologic signs which may not be readily evident. Since it is

a harmless and painless technique, it may be used as a preliminary

searching device in situations where more rigorous methods of study,

such as air encephalography, might be contraindicated.

The EEG has restricted value in the case of deep lying tumors or

other lesions of the brain stem, basal ganglia, hypophysis, and so forth.

Lesions in these areas may be reflected in electrocortical abnormalities,

but in general produce no characteristic changes of the EEG (Walter,

1937), unless increased intracranial pressure is present, or unless optic

or thalamo-cortical tracts are involved. Disorders primarily due to basal

ganglia lesions, as in paralysis agitans (Jasper and Andrews, 1938b;

Schwab and Cobb, 1939), are not readily reflected in the EEG and

throw little light on the nature of the discharges responsible for the

peripheral motor tremors and other involuntary movements character-

istic of some of these diseases. On the other hand, Usher and Jasper

(1941) have found distinct abnormalities in the EEC's of patients with

Sydenham's chorea. The modifications of the EEG, although nonspecific,

were similar to those observed in the records of epileptic patients between

attacks and were roughly proportional to the severity of chorea clin-

ically.

Diffusely distributed, large, rhythmic slow waves are characteristic

of increased intracranial pressure (Walter, 1936, 1937; D. Williams,

1939). There is evidence (Walter, 1937; D. Williams, 1939; Sager and

Herman, 1939), however, that it is not the pressure as such which causes

the slow waves, but rather edema secondary to the pressure, for abnormal

slow waves are more readily reduced by hypertonic infusions than by

withdrawal of cerebrospinal fluid. Intracranial hemorrhage produces

slow waves and sometimes rapid waves in the neighborhood of the

hemorrhaged area (Berger, 1931; Jasper, et al., 1940; Walter, 1940c;

Glaser and Sjaardema, 1941) ; in the case of extensive epidural or

subdural hematoma there is usually a marked bilateral difference with

absence of electrical activity over the area of hemorrhage.

Trauma or head injury produces a variety of changes in the EEG

depending upon the nature and severity of the injury (Glaser and

Sjaardema, 1940; Jasper, et al., 1940; Williams, 1941c, 1941d; Marmor

and Savitsky, 1942). The most common disturbance is that of an exces-

sive delta wave discharge, but the absence of an alpha rhythm, variable

33 ] ELECTROENCEPHALOGRAPHY 1079

alpha rhythms with sudden sharp wave discharges or actual epileptiform

activity may be the chief indication of an acute or chronic disturbance

resulting from a brain injury. In general the more acute and the more

severe the injury, the slower and more prominent the delta wave

activity. According to Williams (1941d), abnormality of the EEC

following head injury is usually indicative of organic cerebral damage,

lie found that abnormality of the EEC may persist in about 50% of

the patients with a chronic post-traumatic syndrome. Although there is

a close relationship between clinical improvement and the return of the

EEC to a normal state, abnormality may persist in the EEC for some

time after clinical recovery appears to be complete; consequently it

furnishes a more sensitive index of cerebral dysfunction than does the

clinical state as revealed by the usual methods of examination. A normal

EEC following a head injury is substantial evidence that cerebral dam-

age has not occurred. Therefore the EEG is useful for detecting

malingering, hysteria, and the presence of other psychogenic factors

which frequently follow accidents.

The abolition, reduction, or other modification of the occipital alpha

rhythm has been noted in patients with defects of the peripheral visual

mechanism or with lesions of the optic tracts (Lemere, 1937; Baudouin,

Halbron, et al., 1939; Postelli and Seidenari, 1939; Seidenari, 1940;

Bucy and Case, 1940). Lemere (1942) has pointed out that this fact

makes the EEG useful for distinguishing hysterical from real blindness.

Bilateral differences in the frequency, amplitude, and amount of alpha

rhythm have been observed in simultaneous recording from homologous

areas of the two hemispheres in patients with aphasia (Marinesco, et al.,

1936b, 1936c, 1938a). Rubin (1939b) reported that areal and bilateral

differences in amount of alpha rhythm constitute valuable cues for

detecting cerebral atrophy.

INFECTIOUS CONDITIONS. Diseases involving the meninges and cor-

tex in a somewhat diffuse, though spotty distribution, usually produce,

during the acute stages of irritation and early degeneration, a widespread

disturbance of the EEG. In patients with general paresis (Berger, 1931,

1932c, 1933b; Bennett, et al., 1940; Finley, et al., 1942), the EEG

has shown marked irregularity of the alpha rhythm and numerous wide-

spread slow waves ; frequently also the beta rhythms, especially of the

anterior head regions, are accentuated. Finley, et al. (1942), studying

a large number of patients with various types of neurosyphilis, found a

variety of patterns of abnormality but no consistent differential features

for the various types. General paresis patients showing clinical remis-

sions following treatment frequently show a marked reduction in the

abnormality of their EEC's and in some cases a complete return of the

records to a normal state (Bennett, et al., 1940, 1942; Finley, et al.,

1942). Hoagland (1936a), investigating the pacemaker aspects of

Cellular respiration as reflected by variations in frequency of the alpha

io8o PERSONALITY AND THE BEHAVIOR DISORDERS [33

rhythm in normals and general paretics subjected to hyperpyrexia

treatments, concluded that there are definite changes in cellular respira-

tion with advancing stages of spirochete infection.

Lindsley and Cutts (1941) made periodic electroencephalographic

examinations of a boy during recovery from acute encephalitis. Three

months after the acute phase of the attack the EEC showed gross slow

wave disturbances, widely distributed over the surface of the head.

Associated with these diffuse electrocortical abnormalities were occa-

sional convulsions and extremely disturbed and variable behavior. Dur-

ing the course of one and one-half years there was complete clinical

recovery and associated with the changes in behavior were distinct im-

provements in the EEG, which eventually also became completely

normal.

It appears that all forms of brain tissue-destroying processes, whether

produced by infections, toxic agents, intra-cranial pressure, circulatory

failure, or direct injury, are usually characterized by delta wave activity

as long as the active process of infringement or deterioration persists.

When the active process of destruction ceases and degeneration of cer-

tain cells or cell groups is complete, there is frequently a return of the

EEG to a normal pattern of activity, providing of course that the area

of destruction is not too large and not too concentrated.

ENDOCRINE AND METABOLIC DISORDERS. Endocrine disturbances,

with or without abnormalities of metabolic rate, are capable of greatly

modifying the activity of the EEG. Hypo- and hyperthyroidism tend to

produce opposite effects ; in the case of the former alpha frequencies are

slowed and in the latter alpha rhythms tend to be abnormally fast (Ross

and Schwab, 1939). Congenitally myxedematous patients, who also

were idiots, showed a number of EEG anomalies including reduction of

amplitude or even absence of alpha rhythm, lack of responsiveness of

alpha rhythm to sensory stimulation, and presence of delta waves of

3 to 4 per second (Bertrand, ct al., 1938; Guillain, 1938). Hoffman,

et al. (1942), found definite abnormalities of the EEG in 18 of 25

patients with Addison's disease, consisting of slower than normal alpha

waves especially over the frontal cortex, unusual sensitivity to hyper-

ventilation with marked slow wave production, and a considerable reduc-

tion of normal beta waves. These workers found that the abnormalities

of the resting records were not modified by hormone treatment, vitamin

B complex, intravenous infusions of glucose, or a diet rich in carbo-

hydrates. On the other hand, Engel and Margolin (1941a) described

a patient with Addison's disease who had marked personality changes

and severe disturbances of carbohydrate metabolism, although the basal

metabolic rate was normal. This patient's EEG showed diffuse and

continuous delta wave activity. Both the patient's symptoms and EEG

disturbances were alleviated by a high carbohydrate diet and adrenal

cortex extract.

Engel and Margolin (1941b) studied two groups of patients repre-

33] ELECTROENCEPHALOGRAPHY 1081

senting what they called exogenous and endogenous deficiency states.

The former was represented by patients with vitamin deficiencies and

abnormal dietary habits; the latter was composed of patients with

adrenal insufficiency. Both groups showed neuropsychiatric disturbances,

hypoglycemia, and cerebral dysrhythmias. After administration of dex-

trose the abnormal slow waves of the EEG disappeared, but reappeared

when the blood sugar level fell again, at which time unfavorable person-

ality reactions also developed. Engel and Margolin conclude that the

EEG furnishes a satisfactory quantitative method of studying the effects

of variations in carbohydrate metabolism on cortical activity, and that it

is a useful correlate of the personality changes resulting from defective

carbohydrate metabolism.

The Electroencephalogram in Psychiatric and Psychologic Dis-

orders. Although numerous studies have been made of psychiatric

disorders, especially of the classical psychoses, no distinctive abnormality

of the EEG has been found which could be said to be pathognomonic of

a particular type of disorder. Various deviations from normal have been

noted but consistency has been lacking and the overlapping of patterns

of activity with those in normals and epileptics has left the results in a

somewhat inconclusive state. This may be due in part to the difficulty

of differential clinical diagnosis or possibly to insufficient detailed

analysis of the electrical records, but it seems more likely that the patho-

logical basis of the psychoses, whatever that may be, is of such a nature

that it is not readily reflected in the over-all picture of cortical activity

provided by the EEG.

SCHIZOPHRENIA. Berger (1931, 1933b, 1937c) recorded EEC's in

schizophrenic patients but found no characteristic deviations from nor-

mal, except during states of excitement or hallucinatory experiences.

He did note that there was some tendency toward a reduced amplitude

of alpha waves and sometimes a tendency toward low amplitude fast

waves such as are observed in tense normal subjects. As previously

mentioned, Lemere (1936, 1938, 1939, 1941) has consistently held the

view that there is a sharp contrast between the EEC's of schizophrenic

and manic-depressive patients, and that this contrast may also be

observed in the records of normals who may be classed as of schizoid

or cyclothymic make-up. He believes that a feeble, irregular alpha

rhythm is characteristic of the schizophrenic, whereas a strong, rhythmic

alpha wave pattern is characteristic of the manic-depressive patient.

Lemere (1941) holds that the low amplitude alpha rhythm in

schizophrenia is "due to a low activity cortex that permits irrelevant

ideas to exist side by side without the energy necessary for proper segre-

gation and rational correlation." Elsewhere (1939) he postulated that

the lack of cortical energy production in schizophrenia is due principally

to a constitutionally inadequate diencephalon. He states (1941) that

clinical observation supports this notion since in schizophrenia there is

an inadequate, poorly sustained affect (thalamus) and a defective, labile

io82 PERSONALITY AND THE BEHAVIOR DISORDERS [33

homeostasis (hypothalamus), coupled with normal or superior intelli-

gence (cortex). He cites as further evidence the fact that insulin,

metrazol, and total-push therapy, which influence the schizophrenic

process, also strengthen the alpha rhythm ; these effects are presumably

accomplished by the action of the agents on the diencephalon.

Grinker and Scrota (1941) also conclude that there is a deficiency

of hypothalamic function in schizophrenia. Their conclusions are based

upon results obtained by recording from the "hypothalamus" and the

cortex. They found that schizophrenics, in contrast to normals and

neurotics, show little electrical reaction of the hypothalamus and cortex

to external cold. Whereas an intramuscular injection of adrenalin

causes a marked effect in normals and neurotics, schizophrenics show

little subjective and usually no objective effect through electrical re-

sponses of the hypothalamus and cortex. Electrical stimulation of the

hypothalamus in schizophrenics produces little or no electrical response

in the hypothalamus or cortex, although in normals and neurotics there

was a marked response from both structures accompanied by subjective

effects as well. Verbal stimulation produced no significant hypothalamic

or cortical response in schizophrenics, but did in neurotic subjects.

Hoagland, Cameron, and Rubin (1937a, 1937b) and Hoagland,

Rubin, and Cameron (1936, 1937), using the "delta index" as a measure

of slow wave activity, found higher values in schizophrenics than in

normals, although there was some overlapping of range values.

McMahon and Walter (1938) criticize Hoagland's delta index as a

measure of disturbance in the EEG of schizophrenics and state that they

were unable to confirm Lemere's results. In fact in contrast to Lemere's

results they report that some schizophrenics show an unusually per-

sistent and prominent alpha rhythm, especially in the post-central

regions. They observed in others a pathological delta wave discharge,

principally in the frontal regions. Neither of these variations was con-

sidered diagnostic nor especially helpful in formulating a theory of the

pathology of the disease.

Rubin (1938b) found that schizophrenics and normals show no sig-

nificant differences in frequency, amplitude and amount of alpha rhythm,

although schizophrenics show more variability from day to day. Rubin

and Cohen (1939) analyzed the EEC's of schizophrenics and normals

with respect to imagery-type. Whereas auditory and visual imagery

types predominate in normal subjects, schizophrenics are said to be

principally of kinesthetic, tactual and temperature imagery-types. There

were, however, no very significant differences between normals and

schizophrenics in the amount of alpha rhythm present, although again

there was more day-to-day variability.

Comparisons of the EEC's of schizophrenics and epileptics have been

made by Gibbs, et al. (1938b), and by Jasper, et al. (1939) ; the former

found likenesses between the EEC's of schizophrenia and psychomotor

epilepsy, the latter also found that about one quarter of their schizo-

phrenics showed evidence of epileptiform activity. In general, however,

33] ELECTROENCEPHALOGRAPHY 1083

Jasper and collaborators found that epileptics and schizophrenics were

represented on opposite extremes of a scale of the amount of alpha wave

activity present in the EEG, with normals holding an intermediate posi-

tion. There were wide individual differences among the schizophrenics

and a wide variety of abnormalities in their EEC's, such as dissociation

of activity in homologous areas on the two sides of the head, poor regula-

tion of frequency and amplitude of alpha waves, abnormal grouping of

potentials and random slow waves of epileptiform type. None of these

abnormalities could be said to be characteristic or diagnostic of schizo-

phrenia.

Davis and Davis (1939) point out that psychotics cannot be recog-

nized by their EEC's, although as a group they show more abnormalities

than a group of normal subjects. With respect to alpha index they

found no significant differences between schizophrenics and manic-

depressive patients, and considerable overlapping by both groups with

the ranges for normal subjects. Elsewhere P. A. Davis (1940, 1942)

characterized the EEC's of schizophrenics as "choppy" and irregular

and with a tendency to low amplitude fast waves; manic-depressive

patients were observed to have more prominent and more regular alpha

wave patterns. Similar observations have been made by Yeager and

Baldes (1937).

Finley and Campbell (1941) found a greater percentage of border-

line and abnormal EEC's among a group of 500 schizophrenics than

among a group of 215 normals. There was a higher percentage of

abnormal records among catatonic-hebephrenics than among other sub-

groups. These authors conclude that there is nothing consistent or

diagnostic about the EEC's of schizophrenics, since a considerable

variety of patterns were found. Although low amplitude fast activity

was common, this type of activity was also observed in the records of

other neuropsychiatric patients, especially manic-depressives. Gibbs

(1939a, 1940) in analyzing the cortical frequency spectra of schizophrenic

patients and normals found that schizophrenics show a disproportionate

amount of energy in the frequency ranges above the normal alpha fre-

quency. Clardy, et al. (1941), recorded EEC's in a small group of chil-

dren showing schizophrenic-like reactions. They stress the importance

of slow waves of about 7 per second and bilateral differences in pattern.

From the foregoing reports it may be seen that there is no character-

istic picture presented by the EEG in schizophrenia and nothing to

clearly differentiate the EEC's of schizophrenics from those of normals

or from those of other psychotic patients. As a group, however, schizo-

phrenics seem to show a variety of abnormalities, mainly of the low

amplitude, irregular, high frequency rhythms. There is also some evi-

dence of slow dysrhythmias and in some cases patterns of epileptiform

type.

MANIC-DEPRESSIVE PSYCHOSIS. Lemere (1936, 1939, 1941) reports

that the EEC's of manic-depressive patients tend to be characterized by

1084 PERSONALITY AND THE BEHAVIOR DISORDERS [33

a strong, rhythmic alpha activity, except in the more severely disturbed

and depressed patients, whose records also show some delta activity.

He explains (1941) the overproduction of cortical energy in manic-

depressives as due to an overactive diencephalon and a secondarily over-

active cortex ; the clinical counterparts of these processes are an exces-

sive affect and intellectual distortions. P. A. Davis (1942) reported

that the EEC's of manic-depressives are more rhythmic and regular and

present a stronger alpha rhythm than those of schizophrenics. In another

study P. A. Davis (1941c) observed that manic-depressive depressed

patients have a tendency toward good alpha wave production with some

slow wave components whereas manic-depressive manic patients show

faster and less regular alpha rhythms mixed with beta rhythms. No

marked change in the EEG occurred, however, when patients passed

from a manic to a depressed phase or vice versa.

ORGANIC PSYCHOSES. Psychoses associated with general paresis,

senility, arteriosclerosis and chronic alcoholism have been studied by

Hoch and Kubis (1941). They found that there was some correlation

between the EEG findings and the clinical status, although there was

by no means an absolute relationship. Abnormality of the EEG was

more common among acute cases where marked mental symptoms devel-

oped rapidly; however, in some cases, both acute and chronic, with

decided psychotic manifestations, the EEG was normal. In the most

deteriorated chronic cases slow waves were frequently observed. They

conclude that the EEG in organic psychoses is most significant when

delta waves are present, for in such cases mental impairment is usually

demonstrable.

NEUROSES. Only scattered observations on the EEC's of psycho-

neurotics have been made and these for the most part present no char-

acteristic picture. The only feature of note is a tendency for instability

of the pattern of activity. In patients with marked tensions and anxieties

there is frequently a suppression of the alpha rhythm and a tendency to

low amplitude beta-like waves. This is also characteristic of some normal

subjects who are unusually apprehensive about the recording procedure,

but usually the effect disappears with reassurances and a better state of

relaxation.

HYSTERIA. Titeca (1938) observed in two cases of hysterical

anesthesia that normal reductions of alpha rhythm could not be pro-

duced by stimulation of the affected parts. He concluded that this indi-

cated a functional isolation of certain nerve centers due to hysteria. In

a patient deaf and dumb from a fright, Paulian, et al. (1939), observed

an absence of alpha waves and numerous beta waves over the frontal and

frontal-parietal regions with attempts by the patient to speak and hear.

After a cure by "torpedoing" the patient with electric shocks on the

neck, head and larynx the alpha waves returned.

33] ELECTROENCEPHALOGRAPHY 1085

BEHAVIOR DISORDERS IN CHILDREN. Electroencephalographic studies

have thrown new light on the possible causes of behavior problems and

delinquency among children. In the absence of physical and neurologic

signs in children presenting behavior disorders of this character the

causes for misbehavior have been sought principally in environmental

factors. All too frequently, however, children exposed to the same types

of unfavorable environment and even members of the same family have

presented striking contrasts in behavior. The first evidence that dis-

turbances of cortical function might play a significant role in such dis-

orders was presented by Jasper, et aL (1938). These investigators

found in a group of 71 behavior problem children that the EEC's

showed abnormalities in 73% of the cases. In addition to disturbances

of the pattern of the alpha rhythm numerous evidences of slow waves

ranging in frequency from 2 to 7 per second were observed. Some of

the abnormalities were suggestive of epileptiform activity. Other workers

(Lindsley and Cutts, 1940; Strauss, et al, 1940; Brill, et al., 1942;

Brown and Solomon, 1942; Secunda and Finley, 1942) studying groups

of problem children have observed abnormalities of various types in from

70 to 90% of the cases.

Not only do the EEC's of such children show a significant amount

of slow activity of 3 and 6 per second, but additional latent signs of

electrocortical disturbances are revealed by a brief period of hyper-

ventilation. This suggests that there is an underlying physiological

instability. Drugs such as benzedrine, phenobarbital and dilantin, which

have been used to control hyperactive and impulsive behavior with some

success, have not on the whole produced significant changes in the

EEC's of behavior problem children (Cutts and Jasper, 1939; Lindsley

and Henry, 1942). This does not necessarily mean, however, that the

electrical disturbances revealed by the EEC in such children are not in

some way partially responsible for the deviant behavior manifestations.

So far no close relationship between the type of behavior disturbance

and the EEC abnormality has been established, but this may be due to

the fact that behavior disorders are unusually labile and subject to

secondary modification by numerous environmental factors. In some

cases the EEC abnormalities have led to closer search for neurologic

factors and have revealed localized cortical defects, but the chief cause

of abnormalities of the EEC in problem children seems to reside in

physiopathologic mechanisms, the precise nature of which is as yet

unknown. There is some evidence that growth and maturational factors

play a part in the physiologic disturbances, for Secunda and Finley

(1942) have reported that the abnormality of the EEC in such cases

decreases with age.

MENTAL DEFICIENCY. Berger (1932c) reported that the EEC's of

feebleminded persons resemble those of normal persons, except for some

reduction in amplitude and frequency of the alpha rhythm in the lowest

1086 PERSONALITY AND THE BEHAVIOR DISORDERS [33

grades of feeblemindedness. Later (1938c) he stated that the EEC of

the adult feebleminded person shows a better resting alpha rhythm than

in normal healthy adults. This he believed was due to their relatively

undisturbed, passive mental make-up. The most extensive studies of

mentally deficient persons have been made by Kreezer (1936, 1937,

1939a, 1939b). By dealing with adult subjects he has in effect been

able to hold chronological age constant, at least in so far as it might affect

the frequency and pattern of the alpha rhythm, and has compared the

EEC's at different mental age levels. In general, he has found in

mongolian and hereditary types of mental deficiency a tendency for fre-

quency, amplitude, and amount of alpha rhythm to increase with in-

creasing mental age. The increase was not a continuous function of

mental age, but was most evident in the region of six to eight years of

mental age. The changes with increasing mental age, though statistically

significant, were not striking and marked individual differences were

noted within a particular mental age level.

SHOCK THERAPY. Finally, one of the uses to which the EEG has

been put is the study of the nature, and effects upon the nervous system,

of convulsive shock therapy. Numerous EEG studies have been made

during, and for varying periods of time after, mctrazol shock (Cook and

Walter, 1938; Rubin and Wall, 1939; Strauss and Rahm, 1940; Davis

and Sulzbach, 1940; Levy, et al., 1942), and electroshock (Levy, et al,

1942; Pacella and Barrera, 1942; Pacella, et al., 1942; Fleming, et al,

1939). The electrocortical discharges during the convulsive shock period

are similar in both cases and resemble the activity recorded in epileptics

during a grand mal attack, except when a subconvulsive dose is given

with resulting patterns of activity more nearly resembling petit mal

attacks. After the first few shock periods there is frequently evidence

of cortical disturbance in the form of spontaneous slow wave discharges.

These usually persist throughout the course of the shock series and for

varying periods of time after the termination of the series. In some

cases delta wave discharges have been present as long as six months

after the period of shock therapy, although for the most part such cortical

disturbances have disappeared within two months. In some patients

making clinical recovery from a previous psychiatric condition, follow-

ing shock therapy, there is evidence of a restoration of the EEG to a

more normal type of picture, whereas in others little or no change

occurs.

From the foregoing account of the use of the EEG in the study of

neurologic and psychiatric conditions it is evident that the most important

applications have been in the field of the former. With further refine-

ment of the technique and better standards of classification of EEG data

in terms of the range of characteristics observed in the records of normal

individuals there is a possibility that the more subtle personality and

behavior distortions observed in psychiatric disorders may be illuminated

by analysis of the EEG.

33 1 ELECTROENCEPHALOGRAPHY 1087

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33] ELECTROENCEPHALOGRAPHY 1091

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33] ELECTROENCEPHALOGRAPHY 1095

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1102 PERSONALITY AND THE BEHAVIOR DISORDERS [33

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PART VIII

THERAPY AND THE PREVENTION OF

BEHAVIOR DISORDERS

Chapter 34

PSYCHIATRIC THERAPY

By KENNETH E. APPEL, M.D.

A CHAPTER ON PSYCHIATRIC THERAPY may seem ironic and futile with

another World War exploding with man's primitive savagery. For

what is psychotherapy but the application of the principles which help us

to control and to use the crude energies of the primitive instincts within

us, so that we can live constructively and socially, and not destructively

and madly? Yet we need not despair if we take a historical or anthro-

pological perspective. It took hundreds of thousands of years for man to

learn to walk upright. He has been using bronze and iron less than

10,000 years. The cultures on which we build, Judeo-Christian and

Greco-Roman, have existed less than half that time. Our Industrial

Age is in its infancy, comparatively speaking. So, from Hippocrates to

Pasteur, from Socrates to Freud, or from King David to Florence

Nightingale, is but a comparatively short time as one measures human

progress. We may be proud, therefore, of the progress in psychiatry

where new methods of treatment and of prevention (see Chapter 35

by Stevenson) have kept and will keep thousands of individuals from

the suffering and ineffectiveness that nervous and mental disease

entails.

A historical perspective shows us five vistas. First, the Ancients

Egyptians, Jews, and Greeks. Secondly, the Middle Ages with theo-

logical conceptions of lunacy and witchcraft. Thirdly, the astrological

tradition represented by Paracelsus and later by Mesmer. Fourthly, the

humanitarian period of Pinel. Finally, the modern tradition which

stems from Charcot.

Ancient medicine considered that disease was caused by evil spirits

or demons (Garrison, 1917). The oldest prescription in existence, one

from Egypt, "calls for the exhibition of a green stone as a fumigation

against hysteria." Early Assyrian tablets contain formulae for driving

out evil spirits causing disease; cures and prevention were supposed to

be effected by magic, charms, incantations, and rituals.

The Judeo-Christian Scriptures contain frequent references to mental

disease and to various forms of healing. When the Spirit of the Lord

departed from Saul and he was depressed, he called for David (1. Samuel

16:1423). David played on his harp before Saul, the "evil spirit

departed from him/' and he was "refreshed" and "well." Nebuchad-

nezzar had a dream which was interpreted by Daniel (Daniel 4:33-34)-

1107

iio8 PERSONALITY AND THE BEHAVIOR DISORDERS [34

He became mad and was driven from men and "did eat grass like

oxen/' but when he lifted his eyes toward Heaven his "understanding

returned/'

In the New Testament are recorded many miracles of healing by

Christ. The leper came asking to be healed and "Jesus put forth his

hand, saying, 'I will; be thou clean/ and immediately his leprosy was

cleansed" (Matthew 8:2-3). Later many "possessed with devils" were

brought to Him and "He cast out spirits with his word, and healed all

that were sick" (Matthew 8:28-33).

Hippocrates attempted to supplant demonological conceptions and

magic with theories and practices based on observation and natural

causes. The Hippocratean description of disease in many instances re-

mains today a part of medical teaching, but the humoral conception of

pathology (see Chapter 1 by McKinnon) has been displaced. Hysteria,

according to Hippocrates, was due to the wanderings of the uterus

through the body in search of humidity. For example, if it happened to

press against the heart, the symptom was palpitation.

According to Galen, hysteria was caused by the engorgement of the

uterus by the menstrual blood. He continued the path toward a merciful

treatment of the insane. Celius Aurelianus in the third century con-

tinued the Hippocratean tradition that insanity was a brain disease and

that treatment should be gentle and kind, which, as White (1905) says,

would have saved fifteen centuries of cruel treatment of the insane had

not theological teachings thrown their influence on the side of the

cruder and more cruel demonological conceptions drawn from Biblical

texts. Alexander of Tralles in the sixth century wrote on the treatment

of melancholia. Paul of Aegina (625-690), under the protection of one

of the Caliphs, stressed the cure of madness as a disease and the neces-

sity for mild treatment.

Unfortunately, for centuries through the Middle Ages demonological

conceptions and magic held practically undisputed sway. Another

quieter, more kindly, self-sacrificing, and charitable tradition stemmed

from the New Testament. It was submerged for the most part but it

carried momentum, and here and there sporadic manifestations appeared

in the form of rude hospitals and infirmaries. The most prominent

of these were the Infirmary of Monte Cassino, the Hotel-Dieu at Lyons

in the sixth century, and the Hotel-Dieu at Paris in the seventh. There

were great charitable organizations, like the Order of St. John of

Jerusalem at the time of the Crusades, which brought the spirit of charity

and mercy to help the sick, wretched, and afflicted of humanity. This

spirit finally blossomed in the labors of modern saints, such as Vincent

de Paul, Elizabeth Fry, Florence Nightingale, and others.

But since cruelty to the lunatic was punishment for the Devil in him,

it was the accepted and prescribed method of treatment for the most part.

The insane were chained, beaten, scourged, and entrusted to the jailer

and torturer. Almost to the seventeenth century madness was held to

be due to possession by Satan.

34] PSYCHIATRIC THERAPY 1109

In 1S47, Henry VIII chartered a hospital in London for fifty lunatics. 1

It was called Bethlem Asylum (Bedlam) and patients from it were

often allowed to beg on the streets. The colony at Gheel, Belgium, was

founded in medieval times as a religious work, and continued this kindly

tradition of Christianity. But it was not really until Pinel (1795) that

the chains were thrown off and the modern humane treatment of the

insane began.

The tradition of the royal touch and the astrological conception of

disease became blended in Paracelsus (1493-1541). He believed that

diseases were caused by astral influences (lunacy, from luna~moon)

acting on man. This tradition with the conception of animal magnetism

culminated in Mesmer (1734-1815). He believed that health and disease

were due to the distribution of a kind of magnetic fluid in the body and

that this could be influenced beneficially by the human hand. There is

no doubt that at times good results followed his treatments, but the

learned men of Paris drove him away because of his charlatanry. How-

ever, the phenomena observed in his patients and their treatment formed

the starting point of modern psychopathology.

From Paris and Nancy, respectively, two or three lines of psycho-

therapy have developed which persist in psychiatry today. From

Liebeault and Bernheim came the Suggestionists (Babinski, Baudouin,

Coue) and the Persuasionists (Dubois, Dejerine). From Charcot came

Janet, Freud, Bleuler, Jung, Adler, Rivers, Ross, and Hart.

Janet, a pupil of Charcot, studied especially hysteria and various

automatisms. To account for these conditions Janet (1889) introduced

the concepts of dissociation, the subconscious, and psychological tension.

To account for the various manifestations of hysteria and psychasthenia,

he assumed that certain mental processes go on in the subconscious inde-

pendently of (dissociated from) the main stream of consciousness. The

conception of psychasthenia formulated by him includes states of fear,

doubt, obsession, and compulsion. The cause of the dissociation he

believed to be the weakness of the (hypothetical) psychological tension.

Janet's "idees fixes" became "reminiscences" in early psychoanalysis.

For him the splitting was chiefly mechanical and due to lack of energy ;

he did not believe in repression.

Freud, born in 1856, first was associated with Breuer in Vienna, later

studied with Charcot in Paris, and then returned to practice in Vienna,

where he developed psychoanalysis, the influence of which has been epoch

making in psychiatry.

Jung, Adler, Rank, and Stekel started with Freudian conceptions

but later broke away and developed their own formulations.

No sketch of this kind would be complete without mentioning Krae-

pelin (1856-1924). He stands in a place alone. He cut across the con-

fusion of psychiatric syndromes and diseases with great insight and

vision, and brought order by introducing the concepts of dementia

L Formerly a monastic institution devoted to the care of the insane.

mo PERSONALITY AND THE BEHAVIOR DISORDERS [34

praecox and manic-depressive insanity. His great contributions were

observation and classification. He stimulated organic research (Mott,

Cotton, Gibbs, Dunlap, N. D. C. Lewis) which has been a continued

inspiration to psychiatrists.

McDougall and Adolf Meyer do not belong to any one tradition. Mc-

Dougall was interested in psychotherapy and practiced hypnosis exten-

sively in his treatment of war neuroses. Adolf Meyer is eclectic. He is

neither an organicist nor a psychogenecist. He is both. His concept of

psychobiology is genetic, developmental, biographical, and individual.

Treatment must necessarily be medical, psychological, educational, and

sociological. He himself is an individual large enough to comprehend a

great whole, and his breadth of outlook has tremendously energized

American psychiatry.

Methods of Psychiatric Therapy

The Symptomatic or Direct Psychological Approaches

Hypnosis. The method of Mesmer, who was born in 1734, which

came to be known as Mesmerism, was really a form of hypnotism. Braid,

following the work of LaFontaine, proved that no mysterious magnetic

fluid passed between the operator and the subject, and originated the

term hypnosis. (For the history of, the theory of, the techniques of pro-

ducing, and the experimental work with hypnosis, see Chapter 16 by

Jenness.)

As a therapeutic method, hypnosis was originally developed in

work with hysteria and hysterical conditions. Charcot, Janet, Bern-

heim, Breuer, and Freud used it not only to remove such individual

symptoms as contractions, paralyses, spasms, and anaesthesias, but also

to remove amnesias. All have emphasized that sudden spectacular results

should not be expected. Although hypnosis is most effective in treating

conversion hysteria, and the war and occupational neuroses, it may also

be helpful in treating the neurotic complications sometimes associated

with organic disease. Diethelm ( 1936) cites, for instance, the case of an

older man who was cured by hypnosis of protracted hiccough that fol-

lowed a prostatectomy. Hypnosis has been used to alleviate pain in oper-

ations and in delivery. It is said to be helpful in treating dysmenorrhea,

frigidity, and impotence, and it is readily applicable in psychogenic mus-

cular disturbances. It has also been used to some extent in treating the

anxiety states. However, for the obsessive-compulsive neuroses, for

phobias of the psychasthenic type, and for altering neurotic characters,

hypnosis is of little help. It is also ineffective for treating the perversions

and the psychoses.

In using hypnosis there is a temptation to attack the individual symp-

tom which the patient believes is the chief trouble. Diethelm (1936),

Schilder (1938), and others have emphasized the inadequacy of such

symptomatic treatment. Psychiatric experience has shown repeatedly

that if causes are not tackled, the fundamental difficulty soon reappears

34 ] PSYCHIATRIC THERAPY im

in the form of another symptom. Hypnosis may, however, be employed

as an aid in the attack upon causes. William Brown (1938) attributed

his successful hypnotic treatment of the war neuroses to catharsis. While

under hypnosis his patients acted terrified. According to Brown's theory,

which harks back to the early conceptions of Breuer and Freud (1893),

this emotion has been repressed, and with it the ability to speak. When

the repressed emotion is worked out by the patient reliving his experi-

ence in the hypnotic trance (abreaction), the cause for the dissociation

is removed. The patient's inability to speak, his memories, and his other

disabilities then disappear (reassociation). Schilder (1938), however,

considered cathartic hypnosis unsatisfactory. Occasionally he combined

hypnosis with interviews from which he obtained an understanding of the

patient's problem. During these interviews he used dream interpretation

and free association, then he devoted the last 15 minutes to a hypnotic

session wherein he gave an interpretation of the origin and nature of the

symptoms and made suggestions that the condition would disappear as

soon as the patient attained insight.

Historically, hypnosis formed a starting point for studies of psycho-

genesis, for psychotherapy in general, and for psychoanalysis. It is today

a valuable tool for the investigation of psychosomatic relationships. Blood

sugar and blood calcium levels, respiratory, heart, and basal metabolic

rates, and peripheral vascular reactions (flushing and skin temperature)

can be modified by hypnotic suggestions (see Chapter 16). American

psychiatric practice has probably not made sufficient use of hypnosis.

Hypnosis has, however, definite limitations even beyond the tempta-

tion to attack the patient's individual complaints. It cultivates dependent

and infantile attitudes. It savors of magic. The attitudes of the hypnotizer

take the initiative and responsibility away from the patient. The view of

the hypnotist as an omnipotent magician is not a wholesome attitude to

encourage in either the patient or the physician. It is bad for the

physician's relationship with his patients except in the most critical

situations. Finally, hypnosis often runs counter to the best principles of

psychological health, namely, the fostering of understanding, of motiva-

tion, of an evaluation of reality, and of a constructive development of per-

sonality.

Suggestion. Probably the oldest form of psychotherapy and the one

in most common use is suggestion. Whenever one human being tries

to influence another, suggestion usually enters in. It is involved in the

psychology of leadership, advertising, propaganda, religious faith and

practice, sleep, hypnosis, and psychotherapy.

Baudouin (1920) defines suggestion as the subconscious realization

of an idea. Janet (1889) follows the intellectualist tradition that sug-

gestion is the implantation of an idea. McDougall (1926) defines sug-

gestion as the acceptance of an idea with conviction without logically

adequate goals for its acceptance. He relates it to the gregariousness of

the species and the conative energy of the submissive instinct which is

i ii2 PERSONALITY AND THE BEHAVIOR DISORDERS [34

touched off by the prestige, authority, verbal expressions, or directions of

the strong. Freudian theories are similar to those discussed under

hypnosis and relate the influence of suggestion to the persistence of in-

fantile attitudes toward the parents which are adopted or transferred to

others (Jones, 1938, pp. 303-304).

When a patient comes to the doctor he is in an attitude of expecting

relief not only from his physical symptoms but from his insecurities. It

is important for the physician to be aware of this psychological condi-

tion even if he is treating an organic illness, and to use suggestion con-

structively and not destructively. It is here that the physician's manner

and bearing are so important. Indefiniteness, lack of assurance, uncer-

tainty, undue gravity, or silence may be devastating to the patient. Such

behavior feeds his imagination and apprehension with all sorts of fore-

bodings. A hasty word or an incomplete explanation may leave the

patient with almost unbearable insecurity or fright.

Kraines (1941) points out that the value of suggestion is shown by

its effects on a wholesome reorientation of the patient's general attitude

rather than by symptom disappearance. Constructive suggestion, he be-

lieves, should help the patient direct his thoughts away from his pains

and difficulties, toward outward and more pleasant possibilities. This

change in attitude should relieve emotional tension so that smooth muscles

relax, and should raise the threshold to pain. Suggestions made on the

basis of a knowledge of the personality factors involved and of the sta-

tistical probability of cure are legitimate and helpful.

According to Diethelm (1936), treatment by suggestion is best used

when the symptoms are not based on marked personality involvement.

Shell shock shortly after its inception, anxiety states after accidents, con-

version symptoms of recent and superficial origin are the conditions

where success is most to be expected. It can be used with immature

personalities or people with lowered intelligence. For obsessive and

compulsive states, and psychoses, it is ineffective. It enters in part

in the various forms of physical therapy such as massage, baths, ultra-

violet light, etc. As Miller (1930) points out, diseased and especially

nervous people are in primitive, regressive states of mind. One of the

characteristics of these states is a tendency toward superstition. "They

do not want a reason, they want a sign." The effectiveness of physio-

therapy, of electrotherapy, and even of mild medicines is not so un-

reasonable as it seems, in view of the psychological state to which

physicians must minister.

Many of the objections that hold for hypnosis apply also to direct

suggestion. Suggestive therapy is symptomatic, not etiological. It is

assertive and authoritative rather than understanding. It is superficial

and dogmatic, not deep. In this sense, therefore, it is only partial and it

is unrealistic. It goes against the fundamental principles of mental

health because it obliterates rather than increases insight. Finally, it is

impotent in severe conditions.

Coue (1929), a nonmedical practitioner, has popularized autosugges-

34] PSYCHIATRIC THERAPY m 3

tion. For Coue, however, all suggestion is autosuggestion. When psy-

chotherapy is effective at all through suggestion, he believes it is the

result of a vivid imagination of a state of health with such conviction

that pathological reactions are excluded. If imagination conflicts with

the will, the imagination always wins out. Coue is undoubtedly right

when he emphasizes that there are many conditions in which suggestion

or imagination are effective w r here reason and the will are impotent.

Furthermore, if his conception of imagination or suggestion be identified

with the unconscious, his theory comes in line with important theoretical

trends in psychiatry. In practice, the patient is taught autosuggestion by

simple methods. He is simply told to repeat to himself, 20 or 30 times

every day, the formula that he is "getting better and better in every way."

There are many objections to Coue's method both theoretically and

practically. It is not really autosuggestion, for the suggestion comes

from Coue or some other healer. The tone of command, the fixation on

the root of the nose, the use of the string with knots in it as a sort of

psychiatric rosary, all his auxiliary practices relate the procedure to

liypnosis. From this point of view a state of dissociation is produced

similar to that in hysteria and hypnosis. William Brown (1938) says

that the conflict is not always between will and imagination but between

a weaker and a stronger suggestion. Again the procedure and the sym-

bolism afford no insight. The self-assurance is given, according to Schil-

der (1938), by the introjected father (Coue). Faith in the outcome is

substituted for effort. The importance of Coue's personality in producing

this faith has been underestimated. His anti-intellectualist and antivolun-

tarist emphasis is right, as is his emphasis on emotion and interest in

determining outcomes. His emphasis on imagination, if we consider this

the unconscious, his emphasis on passivity and absence of effort are im-

portant. They point out the limits of intellect and will power in life.

As a routine scheme the Coue method is not used in psychiatric practice.

But its main tenets have again called attention to the limits of appeals to

reason and will power in psychotherapy which are, unfortunately, all too

frequent in attempts at hasty therapy. The importance of optimistic

representations (imaginations and suggestions) on waking up and going

to sleep, and perhaps repeated during the day, has probably been mini-

mized undeservedly by psychiatry.

Reasoning or Moral Suasion. In 1907, Paul Dubois of Berne,

Switzerland, published a book which was a landmark in the history of

psychotherapy. When most physicians were emphasizing the neuro-

logical or hereditary causes of nervous diseases and treating them by

physical means (see below, the Weir Mitchell treatment), he wrote that

many conditions were purely or primarily psychological in origin and,

therefore, required psychological treatment. Dubois quoted Charcot for

the belief that psychoneuroses arise from two factors, namely, an in-

variable neuropathic (Dubois says it should be "psychopathic") heredity,

and a "provoking agent." If a person gets a nervous disease, one can

in 4 PERSONALITY AND THE BEHAVIOR DISORDERS [34

infer a latent predisposition according to Dubois. Nevertheless, we

should practice "orthopedia" because we pass on not only our heredity

defects to our children, but also we give them the contagious example of

our faults. A man becomes psychoneurotic because of what he owes to

heredity, to atavism, to education, and to his ego. Although the psycho-

neuroses have a physical substratum, this need not mean they have

somatic causes. The weakness, fatigue, and anemia are not the causes.

Psychoneuroses are afflictions of the psychic life ; their source is psychic ;

it is ideation that causes these disorders. The stigmata of the psycho-

neuroses Dubois considered to be : suggestibility, fatigability, exaggerated

sensibility, and exaggerated emotionalism. However, he did not consider

all nervous conditions to be caused by psychological factors, so not all

could be cured by psychotherapy. He pointed out that all clinical syn-

dromes that characterize bodily illness have their counterparts in

nervousness.

Dubois 1 therapy is often called persuasion in the textbooks, but his

theoretical emphasis on rational and moral factors makes it more logical

to refer to his therapy as rational psychotherapy or moral suasion. He

contrasted his therapy with that of Bernheim who considered suggestion

everything. According to Dubois, the patient should develop critical

mindedness and a sense of independence as defenses against suggesti-

bility. He anticipated the opposition to treating symptoms. One should

not treat symptoms directly, but all therapy must be based on accurate

diagnosis, and one should concentrate on changing the system of ideas

through moral suasion. Belief in the possibility of cure must be empha-

sized from the beginning, for once the patient has such a conviction,

he is already better. The keynotes in Dubois' method were encouraging

and moralizing conversations, reasoning as to the nature of the symp-

toms, enlightenment concerning the false ideas and bad mental habits on

which the symptoms were based, acceptance of the symptoms and ignor-

ing their nature, and the belief and conviction of cure. Patients should

be stoical, for instance, and think more of the welfare of others than

of their own misfortunes.

There is no doubt that Dubois' approach heralded a new note in

the history of psychiatry. His book contains numerous examples of

cases, and, because of the frankness of his reports, even when he runs

contrary to his own theory in the use of pure direction and assertion,

they will repay reading by any interested in practical psychotherapy.

Unfortunately, his reports contain too little of what was actually

said and done in a particular case. From the modern point of view,

moreover, we should want to know more about the personalities and

their development in Dubois' cases. His studies did not compare in detail

with the patient investigations that Freud was simultaneously making,

but he was a great clinician, an intuitive, impressive, and successful

therapist. He certainly had adumbrations of the main points emphasized

in modern psychotherapy. For instance, he wrote : "The more I advance

in medical experience, the more I try to make my intervention rational

34 ] PSYCHIATRIC THERAPY 1115

and avoid pure suggestion. One must not confine one's ambition to the

suppression of the actual attack. One must be concerned with the con-

nection of the (hysterical) mentality. Get your patient to confess to you,

and you will detect distressing preoccupations and unhealthy mental

conditions created by the circumstances of her life" (Dubois, 1907).

Clearly, however, Dubois* patients did not improve merely through

his appeal to their intellect and will. His prestige, personal influence,

suggestion, positive assertion, and emotional support entered into his

therapy. He appealed not only to reason but to the emotions and to

various unconscious factors in the personalities of his patients. Although

emotions were underestimated in his theory, a sort of parent-child rela-

tionship was actually established, and faith in a sort of father confessor

and director was probably quite as important in his success as appeals

to reason. Dubois had remarkable success therapeutically, and his theory

marked a distinct advance, but his rational and logical short-cuts to emo-

tional problems were often superficial and inadequate both theoretically

and therapeutically. He relied heavily on the old Christian teaching that,

"If thou canst believe, all things are possible to him that believeth"

(Mark 9:23).

Persuasion. Dubois' theoretical reliance on reason and will power

underestimated the importance both etiologically and therapeutically of

emotion in the psychoneuroses. But his contemporary, Dejerine (1913),

corrected this defect, called attention to and insisted on the importance

of emotion, "Everything that an emotion may create in an accidental

and transient way hysteria may accomplish in a lasting way" (pp. 269-

270).

For Dejerine, emotions (not just wrong ideas, weakened will, and

suggestibility) are causal in the development of psychoneuroses. Emo-

tional shocks and repeated difficulties which cause marked anxiety and

anguish are the starting points. The stimuli may be external, or they

may be internal like a memory of a past event or an idea of future action.

Conflict between our emotions and intelligence is set up, and, in the psy-

choneuroses, the intelligence is overwhelmed. In this process, vicious

circles are established, for the patient may be emotional from lack of

intellectual strength, or weakened intellectually from too strong emo-

tions. Fatigue, overwork, and organic disease may play a role in the

development of nervousness, but emotional disturbance is always basic.

Sexual disturbances increase emotionalism. Functional disorders are, as

it were, "crystallizations" of emotional reactions.

In Dejerine's system, each syndrome had its particular psychopath-

ology. Hysterical conditions arose directly from strong emotional shocks.

Neurasthenic conditions developed gradually from repeated emotional

reactions when the patient could not free himself from the memory of

and preoccupation with them. Hypochondriacal conditions might have

their origin in the emotional uneasiness with regard to health caused by

the overprotection of children. Psychasthenic tendencies and loss of

iii6 PERSONALITY AND THE BEHAVIOR DISORDERS [34

security might arise from urging children to be too concerned with and

anxious about scruples, exactness, and perfection.

In therapy, according to Dejerine, one tries to liberate (release,

abreact) the personality from the harmful emotions and misrepresen-

tations. Thorough examinations are made and no therapeutic efforts are

tried at first. The patient is allowed to talk and his confidence is gained.

His whole life history is gone into with sympathy. He is asked about

any special emotional difficulties, sorrows, or traumatic incidents. The

patient is told of the certainty of the cure. The liberating action of con-

fession (abreaction) is stressed. Explanations of emotions and their

physiological counterparts are given, but Dejerine does not try to impose

his own philosophy on the patient as does Dubois. He maintains that

the patient is not cured by reasoning and logic, but by the affective

relationship with the therapist, which enables him to develop absolute

confidence in the physician. This emotional confidence is the factor that

implements persuasion. The reeducation of bad habits is employed. En-

couragement is used, efforts are made to make the patient feel that he is

capable.

Dejerine's persuasion is thus conceived as a more complicated process

than is either the moral suasion of Dubois or suggestion. According to

the theory of moral suasion, the patient gets well because he believes he

can. According to the theory of suggestion, he gets well because the

doctor says he should. Dejerine's formulations are broader than either

of these. He takes into account the effects of emotional excitement and

fatigue on intellectual function According to the theory of persuasion,

the patient gets well because it has been shown to his satisfaction that

there is no reason, emotional or physiological, why he cannot recover. In

the practice of persuasion, the physician tries to guide the patient in

solving his difficulties, and in correcting his unwholesome habits and

misinterpretations. It should not be forgotten, however, that explana-

tions may act as suggestions.

The work of both Dubois and Dejerine shows them to have been

great clinicians. Their depth of insight, and the warmth and kindliness

of their therapy went beyond their theoretical formulations. They did

not hesitate to use sympathy, support, kindliness, suggestion, and direc-

tion when the human situation demanded it. Modern clinical psychiatry,

outside of psychoanalysis, is in practice a development and elaboration

of the methods of Dubois and Dejerine.

Authority, Direction, and Will. In the usual practice of medi-

cine and surgery, the physician draws on his scientific knowledge and

tells the patient what to do. He expects the patient to accept his pro-

nouncements, to exert his will, and to cooperate in executing the direc-

tions. This practice of physicians in somatic disease leads them to over-

estimate the value of knowledge, reason, and will in the conduct of life.

They project these functions onto their patients. When good results do

not follow their directions in psychological disease, they are disturbed,

34] PSYCHIATRIC THERAPY 1117

and they protect themselves psychologically by attributing obstinacy and

lack of will to their patients. The omnipotency wish of the physician is

thus frustrated, and the desire to dominate and cure by sheer will power

and direction is intensified. This factor is the source of many failures

in psychiatric treatment.

Many physicians prepare elaborate, detailed plans according to which

the patients are to live automatically and obediently. The kind of therapy

advised thus depends much on the needs of the physician himself. Un-

questionably, such authoritative direction of the lives of others has had

its successes. But it does not develop self-reliance, independence, and

the taking of responsibility, which are so important in the return to

psychological health.

Payot wrote a book, The Education of the Will (1909), which de-

scribed this type of treatment, and it had influence in psychiatry. This

type of treatment finds an important place in the regimen of Austen

Riggs. In this regimen the details of daily living are arranged on a

schedule so that life shall be neither desultory nor impulsive, and time

shall not hang heavy on the patient's hands. The routine is reminiscent

of the rules of the old religious orders. At the end of the day the patient

is to review the events of the day, consider his failures and his achieve-

ments, and then plan the next day so that a combination of work, re-

flection, and meditation is afforded. Walsh (1913) urges reflections on

the significance and means of accomplishment. He also stresses the

value of leisure and pleasure in life. Various other direct schemes of

mind and will training have been elaborated by Pere Eymieu (1922),

by Vittoz (1913), by Barrett (1915, 1925), and by Walsh (1931). In

these, any combination of the following aids may be employed : nursing,

occupational therapy, vocational therapy, art, social and religious therapy.

Limitations of space permit no discussion of these.

The purpose of all this regimentation and activity is not merely to

fill up time and to divert the patient, but also to establish certain whole-

some habits. Of course, it is undeniable that having certain actions be-

come habitual and automatic is important. Occupational therapy, one's

regular vocation, and a schedule for daily living may all contribute

toward this. Diverting a patient at intervals from his worries, fears,

and unsolved problems may be wholesome, too. But much therapy errs

in arranging so much diversion that the patient is encouraged to avoid

facing his problems. It thus becomes suppressive and runs counter to

the modern ideas concerning the importance of abreaction and of the

resolution of conflicts. One may, for instance, be able to make a patient

paint or photograph as a routine hobby without any reference to his

feelings or his resistance. But finally, a panic of resistance and aggres-

sion may overwhelm him in an orgy in which he destroys all these ac-

complishments. This happened in a case we have seen. This type of

therapy is based on a faulty psychology of will. In the sense of many

of these writers, will turns out to be the exercise of good habits. Their

therapy assumes a faculty of will. It does not recognize the importance

jii8 PERSONALITY AND THE BEHAVIOR DISORDERS [34

of emotion, early training, experience, and conflict in the development

of the psychoneuroses (see Chapter 29 by Malamud). It ignores the

important factor of interest, both conscious and unconscious, which

James long ago (1893) pointed out as the determinant of the "impulsive

and inhibitive quality" of objects and of ideas that come to mind. It

also ignores the "inspired purpose" and the devotion to great causes

emphasized by Walsh ( 1931 ) .

The Physical Methods of Treatment

Rest Treatment. Of the physical approaches, the "rest cure" of

Weir Mitchell (1893), first described in Sequin's Series of American

Clinical Lectures (1875, Vol. 1), is most famous. Mitchell greatly em-

phasized physical factors, and especially the loss of weight, in his con-

ception of nervous afflictions. He believed that rapid thinning was

almost always accompanied by anemia. Fat was his index of health,

and a gain in weight meant an increase in red blood. Weight, fat, and

blood were the three great factors he tried to improve.

Mitchell's treatment consisted in the combined use of isolation, rest,

diet, massage, and electricity. He made no great claim to originality

because all of these methods had been used separately by other physi-

cians. His originality consisted in the regular and systematic use of

these procedures combined. The reason rest failed to cure many patients

treated by other doctors was, he thought, because it was used without

isolation from relatives, or without a dietary push, or without the

simultaneous use of massage and electricity. Electricity, he believed,

toned up the muscles and made up for the lack of exercise, increased

the temperature of the body, fostered relaxation, and toned up the

circulation. Cases to be so treated were: patients convalescent from

fevers, those suffering from constant dyspepsia or "malarial poisonings,"

and cases of nervous exhaustion with spinal irritation and hysterical

symptoms, with many aches and pains, and with loss of weight and

anemia but without organic disease.

Although Mitchell's physiological considerations were not completely

adequate, there are unquestionably sound aspects of his treatment. Rest

in bed reduces tension and its harmful effects in many, but not all, cases.

Adequate nutrition and frequent feedings favor absorption and assimila-

tion. We have used insulin injections in certain cases in which severe

and dangerous undernutrition was apparent (Appel, et a/., 1929).

Massage keeps up muscle tone, favors relaxation, and aids circulation.

Isolation from emotionally disturbing factors is absolutely necessary at

times.

However, the most important factor in Mitchell's use of his method

was the influence of his distinguished and authoritative personality.

Such factors as suggestion, reassurance, support, hope, and persuasion

were probably more important than his physical procedures, although

they did not figure in his theory. Many other physicians using his

34 J PSYCHIATRIC THERAPY 1119

methods mechanically have failed because these psychological factors

were unrecognized. Furthermore, rest will not cure a fatigue which is

the result of unconscious resentment. In such patients rest treatment

is only symptomatic therapy. In a patient we saw recently, the only

hope of curing the chronic fatigue was not in rest, but in discovering

and making conscious the etiological factors of aggression and resent-

ment, and in dealing with them.

Relaxation Therapy. In his talks to teachers and students in

1892, William James (see James, 1915, pp. 54-55, 119) gave the psy-

chological and philosophical background for many of the therapies

of relaxation that were developed later. Their soundness and efficacy

as valuable implements of therapy are, unfortunately, too often ignored

by psychiatrists.

James quoted the observations of Hindu visitors to this country who

noted the tense countenances, ungraceful and anxious expressions of so

many Americans. These visitors could not comprehend our living with-

out devoting any portion of our day to meditation and tranquillity.

James thought that this overmotion (overmobilization of Riggs, 1922)

was causing a "grievous national harm." In his famous theory of emo-

tions, James (1893) emphasized the "organic stirrings" as constituting

a large part of what we call emotion. Put extremely, we are sorry

because we weep, or we are afraid because we run away. Although

this conception is not wholly true (see Cannon's theory in Bard, 1934),

it has a core of truth in it, and it provides an important therapeutic lever

in psychiatry. If we pay little attention to how we feel and concentrate

on what we do, and, if we think of ideas, goals, ideals, and action, the

feelings will gradually be indirectly and unconsciously controlled. Regu-

lated action will thus indirectly control feeling and its associated

autonomic disturbances: palpitation, tachycardia, diarrhea, and abdom-

inal pain. The corollary of all this is to act as if we were kindly and

cheerful and courageous when we feel the opposite, and not pay too

much attention to the feelings.

James (1902) argued that the cause of nervous breakdowns is not

hard work but the feelings of rush, hurry, tension, dissatisfaction,

solicitude, and untoward anticipations. Strong feelings about self or

one's responsibilities "cramp" or inhibit the free association of our ideas

and our motor responses. Relaxation, equanimity, faith, and devotion

to great and extra-individual causes, he believed, should be cultivated.

In this connection, James referred to the important work of Annie

Payson Call, a nurse of nervous patients who worked out an unusually

successful scheme of treatment and a philosophy of practice which is

summed up in a remarkable book, Poivcr Through Repose (1891, 1914).

Her methods were not purely physical as Weir Mitchell's were, at least

theoretically. They involved relaxing exercises, and mind training for

rest, repose, and "power" for effective action. She believed that we

have perverted nature's laws in our rush and strain of living. She advo-

1 120 PERSONALITY AND THE BEHAVIOR DISORDERS [34

cated that one should learn to rest throughout the day by, for instance,

relaxing while sitting in a train instead of trying to help it along, that

one should learn to wait without tension and impatience, and that one

should avoid rapid thought and misdirecting thought. She emphasized

the effect of relaxed muscles in cultivating sleep.

In her philosophy, Miss Call believed that body training was also

mind training. To learn a new movement, we must forget the old one

and relax. She considered worry to be "brain tension" which leads to

fatigue and illness. Along with her physical exercises and mind train-

ing, she utilized moral training in which she emphasized social rela-

tionships. As axioms she used such thoughts as: "one cannot be

happy without considering others" ; "one must develop tolerance" ; "one

must train oneself to yield as well as to direct."

A little book by Rippon and Fletcher (1940), which describes a

combination of training in relaxation with psychotherapy, is one of the

most stimulating and helpful that has come to our attention. The relax-

ation exercises are very similar to those recommended by Annie Payson

Call. However, just as Jacobson (1934, 1938) has extended these

training techniques and supported their significance with electro-physio-

logical investigations, Rippon and Fletcher have extended her moral or

psychological therapy.

Their theory of neurosis is approximately as follows. The environ-

ment stimulates the organism both physiologically and psychologically.

The primal stimulation is insecurity and inadequacy [see resemblance

to Horney's (1937) theory]. Normal development so organizes the

responses to this state of insecurity or inadequacy as to overcome it

successfully. Inadequacy is a "natural incentive to growth, development

and achievement." Health is not a static state of completeness but a

succession of challenges to inadequacy and achievement. In the nervous

disorders, however, misinterpretations, inadequate and overreactive

responses produce anxiety which they discuss chiefly from the Adlerian

point of view. For Rippon and Fletcher, anxiety is the core of neurosis,

as Sidis (1916) believed long ago.

Their therapy begins by getting the patient to relax and cease all

effort at definite intervals. They teach relaxation by Call's method. An

attempt is then made to draw the patient out, which tends to establish

the confidence that will lead him later to discuss personal matters.

Encouraging him to cease all effort diminishes his desire to fight his

situation and revolt against his weakness. Gradually he learns what his

pattern of life has been, how it has failed, and he is thus helped to

develop a new and more satisfactory pattern. In this therapy they

utilize the meaning of symptoms, a tactful and unhurried elucidation of

their development, the emotional relationship between patient and physi-

cian, reassurance, and imaginative exercises which are perhaps remi-

niscent of Coue. They also utilize inspiration and the development of a

wholesome attitude toward life and reality (religion). Their discussion

of the attitude with which the patient with anxiety, whether from

34] PSYCHIATRIC THERAPY 1121

organic disease or neurosis, comes to the physician, and of the attitude

with which the physician should approach such patients could be read

with profit by all physicians and psychiatrists.

The method of Rippon and Fletcher has some kinship with psycho-

analysis. Processes of regression, conflict, abreaction, misinterpretation,

and the development of insight are clearly implied. But free association

is not used. The transference relationship and identification are obvi-

ously implied, but they are not analyzed. The development of the indi-

vidual is not considered in such great detail as in psychoanalysis. Their

method is essentially reeducational. Notwithstanding these criticisms,

the book of Rippon and Fletcher gives an understanding insight into the

nature and practice of psychotherapy that few can equal in so small a

compass. 1

Physiotherapy. The use of physiotherapy or physical therapy in

nervous and mental diseases is often a valuable procedure. Clearly, its

most definite indication is the use of electro-shock in the extreme dis-

orders of affect and motor activity, seen in the manic-depressive psy-

choses or involutional melancholia. The value of the continuous bath in

states of psychomotor agitation and insomnia is proved. The sedative

effects of massage are definitely helpful in restlessness and mild agita-

tion. The stimulating effects of more energetic massage, of the salt

glow, and of faradic current are helpful in psychophysical retardation

and in asthenic states. The various douches and showers may be used

for either their sedative and counter-irritative effects or their stimulating

effects. Nevertheless, physiotherapy for the most part remains empirical

and experimental. It is a useful adjunct in psychiatry and may often be

used as a step in establishing the transference required for psycho-

therapy.

In all types of physiotherapy, one must bear in mind that the effects

attributed to the physical agents may be due to psychological factors

1 Another method with some slight kinship to these relaxation methods is that

of F. M. Alexander (Man's Supreme Inheritance, New York: Button, 1918, or

latest edition, 1941 : Constructive Conscious Control of the Individual, New York :

Button, 1923; and The Use of the Self, New York: Button, 1932). Alexander

believes that most people use their bodies incorrectly in that they let movements

of the extremities interfere with the major tonic patterns. This interference leads

to harmful tensions which cause general and local disabilities. Alexander teaches

his "pupils" (he does not profess to be a therapist) to inhibit spontaneous move-

ments until they can be executed without disturbing the basic head-neck-trunk

relationship ("primary ^control"). He presents^ several cogent arguments against

specific and local exercises or attempts to obtain relaxation directly. His method

seems to result in general changes (e.g., mood and outlook) as well as specific ones.

Although Alexander's theory was developed independently, it is consistent with

the findings of Coghill (Anatomy and the Problem of Behavior, New York: Mac-

millan, 1929) and Magnus (see either R. Magnus's elaborate monograph: K or per-

stellung, Berlin: Springer, 1924; or J. G. Busser de Barenne's brief summary of

this work in "The labyrinthine and postural mechanisms/' in C. Murchison, A

Handbook of General Experimental Psychology, Worcester, Mass. : Clark Univer-

sity Press, 1933). It has received considerable attention in England, but is still

relatively unknown in America, despite Bewey's support. (Editor)

1 122 PERSONALITY AND THE BEHAVIOR DISORDERS [34

working unconsciously and automatically, and caution is necessary in

the proper evaluation of the factors contributing to improvement or

cure.

The psychological benefits of various physiotherapeutic measures may

or may not be well grounded physiologically. The physical contact

which the physiotherapist's procedures require diminishes the feeling

of isolation in the depressed patient, and tends to interrupt the autistic

reveries of the withdrawn schizophrenic. These measures help to estab-

lish social rapport and almost physiologically stimulate socially approved

reaction patterns. A sedative effect is accomplished not only by the

psychological accompaniments of physiotherapy but also often by the

direct metabolic effects of the baths, the packs or the radiant therapy

and massage.

Like most physiotherapeutic measures, massage was employed by the

ancients. Weir Mitchell and Douglas Graham added to its scientific

repute. Hydrotherapy began with the first bath taken by man. The

solvent, stimulating, sedative, and eliminative use of water has been

proclaimed throughout the history of medicine. Benjamin Rush of

Philadelphia used compresses, and he introduced the use of the ice bag.

In the management of the nervous and mental patient hydrotherapy

plays a most important role. The use of hot or cold water under pres-

sure combines the use of water, temperature, and pressure. The effect

gained from the use of massage may be obtained from the use of water

with pressure. In this combination a strong stimulative, eliminative, and,

if continued, sedative effect may be obtained. Baths, as used in psy-

chiatric therapy, are usually of the continuous type and are employed

largely in treating delirium and the excitement of mania or agitation.

In many cases, this sort of treatment precludes the necessity of using

chemical restraints or large doses of hypnotics.

Cryotherapy or the use of cold as a physiotherapeutic measure is less

well understood and consequently employed less frequently than thermo-

therapy. More recently, following the work of Fay, the employment of

cryotherapy over longer periods of time has been recommended as an

alternative procedure to the pharmacological and electric treatments.

Conversely, fever therapy, following its dramatic benefits in paresis,

has been used by many in the treatment of the maior psychoses, but

results have been almost universally unsuccessful.

Medication and Shock. In psychiatry, pharmacological agents are

employed to alter the maladaptation of the patient to his milieu both

internal and external. The types of drugs from which one may choose

are many, and the medication must be prescribed individually with full

knowledge of the patient's specific condition, and his reaction to seda-

tives, and with the goal to be accomplished in view. The judicious

administration of carefully selected medication is invaluable in the treat-

ment of mental illness. It enables us to control symptoms, to interrupt

the stereotypy of mental and physical functioning, to gain access into the

34] PSYCHIATRIC THERAPY 1123

psychology of the patient, and to render nursing care and social guid-

ance more frictionless and effective.

Of the specific drugs, chloral is the oldest of the group. Its action is

certain, prompt, and lasting, and its effects are easily graduated by the

dosage. It has an unpleasant taste, and may be followed by cardiac

and respiratory depression. Paraldehyde is milder in proportion to the

dosage, and there are no depressive after-effects, but it is less certain in

its action. It has its primary use in psychiatry in the control of with-

drawal symptoms following alcoholism. The barbituric acid derivatives

are the most widely used of all the hypnotics and their degree of action

can be graded by appropriate dosage from a sedative effect to the pro-

duction of coma. There are a great number of these derivatives, and it

is preferable for the clinician to become acquainted with a few of the

shorter and longer acting drugs and confine himself to these.

Besides the use of sedative drugs to produce sleep or to allay anxiety,

pharmacological agents to induce prolonged narcosis were early recog-

nized to have great psychiatric value. Such treatment interrupts the

vicious cycle of psychotic thought processes by inducing a physiological

state of quiescence, albeit chemically accomplished. Its greatest field of

usefulness is in the management of acute illnesses in young, physically

healthy people of more than average intelligence. Narcosis permits

access to the patient while his resistance is lowered; it brings to light

material of inestimable value in the later phases of therapy ; and it makes

for quicker rapport. Palmer and Braceland (1937) present a compre-

hensive review of this form of therapy.

Insulin treatment of schizophrenia, since Sakel (1937, 1938) first

described the use of this technique at the University Clinic of Vienna

about 1930, has undergone considerable variation in the actual pro-

cedures. In this method, a reduction in blood sugar that finally gives

rise to prolonged coma is effected through large doses of insulin. A

major need in such therapy is the adaptation of the basic technique to

fit the daily needs of the individual patient (see review by Shipley and

Kant, 1940). This leads to an eclectic type of treatment. The greatest

indication for the use of insulin treatment is schizophrenia when a patient

is not improving after the usual psychiatric therapy. Schizophrenics

may have their delusional, isolated thinking interrupted for one or two

hours after such treatment, and this may provide a therapeutic lever.

Its use for all other psychiatric conditions is contraindicated. Neither

should it be used when various organic diseases would make such

therapy dangerous. Insulin treatment increases the percentage of remis-

sions (see statistical section below), and shortens the illness in those

who recover spontaneously. On the other hand, it is a long and costly

therapy, and contains some danger to nerve cells and to life.

Metrazol, since its introduction by Meduna (1935), has gradually

been relegated to the list of therapies used relatively infrequently, and

this principally because of the advent of electric shock. In this treat-

ment, intravenous injections of metrazol produce epileptiform convul-

ii24 PERSONALITY AND THE BEHAVIOR DISORDERS [34

sions in the patient (for description see Straus, Landis and Hunt, 1939).

It is useful in the affective psychoses, in involutional melancholia, and

in some of the acute catatonic episodes in very young people. It should

not be used when electric shock is available, however, or when there is

clinical cardiovascular disease, marked arteriosclerosis or hypertension,

or when there is marked pathology. It has the advantage of requiring

no special equipment, and it is a respiratory stimulant. However, the

treatment is frightening to the patient, and there is danger of fracture.

It is also capable of effecting changes in the heart musculature, and of

causing damage to brain cells.

Electro-Shock. Electricity has been used in the treatment of

mental disease almost from the time of its discovery. At first, it was

considered a "suggestive agency." Faradic current, however, is a valu-

able muscle stimulator. It can produce muscular contractions almost to

the point of tetany. It is a useful vascular stimulant in sluggish, weak,

or asthenic patients. The sinusoidal current has a marked trophic effect.

It is an excellent stimulant for unstriated muscles where it causes very

little pain.

Recently, Cerletti and Bini (1938) introduced an electrical shock

treatment in which electrodes are applied to the head so that measured

currents can be passed through the cerebral tissue. This produces a

controllable epileptiform seizure. Like metrazol, it is used primarily in

the affective psychoses, especially the depressions and involutional melan-

cholia. It is sometimes used in schizophrenia after insulin has failed,

but the results have been disappointing. Less anxiety is created by

electro-shock than by metrazol. There is no anxiety over missed con-

vulsions, and the convulsions are less severe than are those produced by

metrazol. The patient does not remember the treatment. Fracture and

mortality rates are also lower with electro-shock, but there is still some

danger of fracture, and the danger of damage to brain cells and to mem-

ory is greater than with metrazol.

Surgical Therapy. Various surgical treatments of nervous diseases

have appeared historically, but only two modern techniques deserve men-

tion. In the second decade of this century, Cotton (1921, 1922) tackled

the problem of focal infection in these diseases. He believed that in-

fections were more important as causes than are heredity, environment,

improper training, or personality defects. He believed that emotions

by way of their effect on the ductless glands could reduce resistance to

infection. Thus, psychogenic factors could cause disturbances, but in-

fection was the primary factor. Streptococci he considered the principal

offenders, and they were followed by the staphylococci and the colon

bacilli. He found tonsillar infection in 85% of his toxic psychoses, and

he believed that the sinuses often became infected from the teeth and

tonsils. Secondary foci of infection developed in the gastrointestinal

tract. The cervix, tubes, ovaries, and seminal vesicles were also often

infected. He believed that the disturbances in behavior resulted not from

34] PSYCHIATRIC THERAPY 1125

the actual infecting organisms themselves but from disturbances in the

brain brought about by the toxins produced by these organisms. People

were affected in different ways because the various strains of strepto-

cocci had selective affinities.

From this theory of cause Cotton turned for therapy to surgical

removal of the foci of infection. Not infrequently several operations

were performed on a single patient, and he reported remarkable results.

In addition to removing the foci of infection, Cotton used diet, rest, and

hydrotherapy, but he advised against psychotherapy.

Other psychiatrists soon turned to a controlled investigation of

Cotton's theories and therapy. Kopeloff and Kirby (1923) removed

the foci of infection in a group of 58 cases and left them in a control

group of 62 patients. They found the recovery rates to be approximately

the same in both groups. Kopeloff and Cheney (1922) carried out a

similar study, and concluded that surgical removal of foci of infection

produced no recovery, for no recovery took place which had not been

oredicted from clinical considerations before the surgery was undertaken.

Therapy by means of brain surgery was introduced by Moniz in

1936 (see Freeman and Watts, 1942). In this technique, the fibre tracts

connecting the prefrontal areas with the thalamus are severed. It is most

useful in chronic cases of agitated depression or involutional melancholia

where other forms of therapy have failed, but it has been used to treat

the whole gamut of psychiatric disorders. On the basis of over 80

successful operations, Freeman and Watts (1942) believe that this oper-

ation reduces the emotional reactions of the patient, especially the anxi-

eties that concern himself. Tests of personal characteristics applied

before and after such operations indicate a widening of the individual's

horizon, reduction in preoccupation with self, and a general shift in the

direction of extraversion. The depressed and obsessive become cheerful,

outspoken, and often tactless. In some patients this may result in in-

dolence and lack of tact, but Freeman and Watts report that many of

their patients have attained their prepsychotic level of occupational ad-

justment, and some have even surpassed it (see statistical section below).

Transitory disturbances of memory and other functions have been re-

ported lasting as long as several weeks, but permanent undesirable

sequelae appear to be rare.

Psychological Approaches Involving Reorganization of the

Personality

Psychobiology. Early in this century, Adolf Meyer, through the

influence of Forel, became dissatisfied with Kraepelinian formulations.

A study of Kraepelin's statistics showed that they varied from year to

year and indicated that his disease entities were not clearly defined.

Meyer (1908, 1928, 1938) concluded that Kraepelin's disease entities

were really but types of reaction to difficulties or the results of difficul-

ties in development. He therefore discarded the concept of mental

m6 PERSONALITY AND THE BEHAVIOR DISORDERS [34

diseases for that of reaction types. He argued that psychiatrists should

study what is going on, "what is doing" in their patients, instead of

searching for nerve cell changes and schemata which are largely hypo-

thetical. Etiology should be sought in constitution, in exogenic, in

organogenic, in psychogenic, and in social factors. This study of the total

human being, of activities which cannot properly be considered to be

the function of any part of the organism, or even merely of the brain,

Meyer (1935) called psychobiology. These functions of the total organ-

ism he termed ergasias.

Therapy, according to Meyer, should endeavor to regulate and guide

the patient's life after the factors favoring or hindering modification

have been carefully studied and formulated. Our therapeutic goals should

be to restore security, independence, and integration within the social

group. Psychobiological therapy is conducted through what is called

distributive analysis and synthesis (Diethelm, 1936; Muncie, 1939;

Kanner, 1935). One first observes and analyzes the factors and situ-

ations concerned with the origin of the patient's condition. Then one

synthesizes the facts which will contribute to the patient's security and

to his successful biological and social adaptation. The process is one of

education.

Adolf Meyer's psychobiology has exerted a highly beneficial influence

and has been important in molding the whole trend of American psy-

chiatry. It broke away from the artificial academic dichotomy of mind

and body and brought psychiatry into the realm of biological science. It

brought psychiatry and medicine closer together, and it contributed to

the emergence of psychosomatic medicine. It has also brought psychiatry

into close and important relation with sociology and education. Meyer

has always emphasized optimism instead of fatalism in therapy.

Notwithstanding these positive contributions, Meyer's psychobiology

is justifiably open to many criticisms. Muncie (1939, p. 146) gives some

of these. There certainly is an underemphasis on unconscious processes.

As does Adler, Meyer has assumed that question and answer procedures

will discover and make clear to the patient the source of his difficulties.

This overemphasizes the patient's capacity to reason, for there is no

guarantee that once a patient has understood his difficulties, he will be

able to effect the necessary changes. Meyer's form of therapy makes

little or no use of free association, which itself is an ergasia or function

which is not pathological, and which certainly favors the development of

insight and new perspectives. Many patients lose intellectual interest,

therapeutic enthusiasm, and become pessimistic after the exhaustive re-

view of conscious facts and factors and the development of conscious

formulations. For these cases the psychoanalytic procedure frequently

offers patients something to chew on both intellectually and experi-

mentally in living, and it tends to keep their enthusiasm and hope alive.

Psychobiology has emphasized the study of patients rather than a tech-

nique of therapy. As therapy it is perhaps too simple and general to be

effective in many cases. It definitely does not belong to the group of

deep therapies.

34] PSYCHIATRIC THERAPY 1127

Reeducation. Austen Riggs (1922, 1929) developed an effective

elaboration of psychobiology that is especially applicable to the psycho-

neuroses. As Adolf Meyer worked out his theories and therapy in hos-

pitals devoted chiefly to the psychoses, Riggs developed his philosophy

and his therapeutic methods in a restricted community at Stockbridge,

Mass., devoted to the treatment of the psychoneuroses. Riggs' philosophy

and his practices were eclectic, and various aspects of them show rela-

tionships with those of Bernheim, Dubois, Dejerine, Payot, James,

Cannon, MacDougall, Meyer, and Adler. Like all these men, he empha-

sized psychological factors in the etiology of the psychoneuroses. In

researches, he showed statistically that the causative factors for the

majority of psychoneuroses cannot be found in the present environment

of the individual. Nervousness, he argued, is a disorder or a conflict

within the various levels of the individual : the reflex, the instinctive, the

intellectual, the social, and the ethical (see relation to Meyer's formula-

tions). Emotional strains in overreactive and overtemperamental per-

sons produce the phenomena which are called symptoms, and these are

misunderstood by the individual. The intensity of the overreactivity, or

"overmobilization," may impair even the intellectual functions, thus the

psychoneurotic misinterpretations, and in the more serious conditions

the intellect shows only defective and distorted function.

For therapy, Riggs advised a temporary environmental change, for

example, to a sanitarium such as Stockbridge. Such a change removed

the patient from the strains of his usual vocational, social, and home

environment. In the sanitarium, the patient saw his doctor daily for

discussions. Lectures and group discussions on the psychology of human

behavior and adjustment were given the whole group of patients daily.

Cooperation in social living was stressed. The patient was told that he

needed a process of reeducation, that he must go to school to learn the

principles of personal efficiency. It was explained that the physicians

and the organization would try to make him comfortable, but that com-

fort was purely a secondary consideration. Riggs died recently, but his

eminently effective methods are being carried on by various groups

throughout the country.

In the restricted community at Stockbridge, a schedule of activities

is provided. This regularizes life. It removes the necessity of taking

initiative and of making independent decisions. Like Payot's regimen, it

distracts and diverts the patient; it develops the momentum of good

habits ; it affords practice in doing things because they are to be done,

and allows no avoiding them because one does not like doing them. And,

following James' philosophy, the regimen helps divorce feeling from

action. In the regimen, a period of occupational work such as weaving,

wood carving, basketry, or mental work is provided for each day.

Periods are allowed for exercise, for rest, for relaxation, and for the

diversions of social intercourse at meals and in the evening.

The foundation of Riggs' therapy was, thus, more than intuition

and inspiration, even though these entered into Riggs' personal work.

It followed definite principles. Riggs himself was a charming and

H28 PERSONALITY AND THE BEHAVIOR DISORDERS [34

imaginative person with whom people liked to be identified. This made

his analyses acceptable to his patients. His procedures, furthermore,

were definite, simple, and optimistic. One of Riggs' greatest influences

was the effect which his conceptions and practice had in helping elimi-

nate the embarrassment and stigma connected with nervous conditions.

He tended to make them respectable. His writings and lecturing in col-

leges helped, as did those of Beers (1908), to foster the mental hygiene

and child guidance movements in this country and to make them funda-

mental in education, sociology, and preventive psychiatry.

The same general objections that have been offered in connection

with Adler's and Meyer's formulations and with "directive" therapy

apply to Riggs' theories and procedures. Both Meyer and Riggs devel-

oped their thinking and methods of treatment in connection chiefly with

hospital or sanitarium practice. Both developed institutions far advanced

in their approach to mental and nervous conditions with standards unsur-

passed in their time. However, both have, by the nature of their organi-

zations, concentrated on only part of the field, and their theory and

practice reflect this situation. Their procedures of therapy have become

too organized, too regimented, too directive. They have worked in

environments which could be controlled. Such therapy is apt to give

insufficient weight to unconscious factors. Perhaps this arose in Riggs'

case because of his intense opposition to psychoanalytic formulations.

But a psychology that does not recognize the importance of the concept

of the unconscious is bound to be partial and in many cases ineffective.

Throughout Riggs' writings one recognizes a tremendous emphasis

on the importance of social goals and on ideals for successful adjustment.

Dignity, discipline, ideals, and the influence of reason "sign up for an

ideal" permeate his writings. Certain patients have felt his standards

were stern, stoical, and dogmatic and even Calvinistic. To be sure, Riggs

himself counseled avoiding the New England conscience, out patients

felt it implied in his recommendations. As with Adler's writings, people

often feel, after having read Riggs, that they have fallen down morally

in their job of living, that their pattern of life has not only been an

inefficient mistake, but also a moral defalcation.

EXPLANATORY OR NOETIC THERAPY, INTERPRETATIVE THERAPY, AND

BIBLIOTHERAPY. These methods of reeducative therapy frequently over-

lap. Explanatory therapy shows the patient the mechanism of his symp-

toms but tends to be diagrammatic and mechanical. It is symptomatic

and tends to focus on the present. Interpretative therapy tries to unravel

the meaning or purpose of the condition and is more dynamic and

biographical. It stresses process and teleology. Bibliotherapy uses both

to enlarge the patient's knowledge and insight and is more theoretical

than the others and tends to focus on human nature. Of these, explana-

tory psychiatry is the easiest, interpretative is more difficult and full of

pitfalls, and bibliotherapy is apt to be too general.

Explanatory therapy is an attempt to make clear to the patient his

34? PSYCHIATRIC THERAPY 1129

psychological machinery and how it works. Thus, it is a process of

instruction. The physician teaches, explains, makes graphic the picture

of the production of the symptoms as he sees it and tries to communicate

this to the patient. It is an external communication to the patient of the

psychiatrist's knowledge or understanding of his condition with the

belief that the acquisition of this knowledge will cure it. As such, it is

an attempt to implement will power with knowledge in the organization

of the personality. In this type of therapy the physician may be quite

active and aggressive, or more passive and suggestive. He can expound

the principles of psychology and mental hygiene, or he can guide the

patient to read about them and discover them in himself. After having

read of a particular mechanism or having had it described by the physi-

cian, the patient explains it back, then he explains the mechanism of his

own symptoms. It is easy to go from this type of therapy to interpre-

tative psychiatry and even ultimately to free association and analysis.

Sometimes it is the only possible approach some patients will accept, just

as the psychiatrist is forced to start his psychotherapy with purely medi-

cal treatment in some instances.

The most satisfactory approach to explanatory therapy of which we

know is in Riggs' (1922, 1929) books and pamphlets. One can, from

the interim experiences and symptoms which the patient describes, use

these as texts of psychology and elementary physiology. It is a simple

matter to point out the relations of fear and tenseness, of worry and

anorexia, of apprehension and palpitation, of excitement and flushing,

of resentment and nausea, of depression and loss of weight, of insomnia,

fatigue and emotion, and of emotional urgency and insecurity. The more

simple psychological mechanisms can readily be explained, and the sim-

pler displacements can be made clear and understandable. However,

complicated displacements, reaction formations, substitutions, symbol-

isms, identifications, and projections can be explained only with diffi-

culty. And if they can be explained they are frequently not understood,

at least to the point of being serviceable in the therapeutic process.

Explanatory psychiatry forms the easiest and most ready introduction

to psychology, and it is permissible to use it in any case except where

one is sure that psychoanalysis is indicated and will shortly be used.

One can employ it too early in treatment, however, before the patient

feels that he has had an opportunity to say all that he has to say. The

physician has to sense that the patient is ready for it, or that he has

become discouraged with exhaustive physical and laboratory examina-

tions and purely medical treatment, and will tolerate a consideration of

some new aspect of his condition.

Interpretative therapy goes deeper than the explanatory method. It

is interested in the significance of symptoms and in their function. In

interpretative therapy, the psychiatrist tries to see the symptoms as part

of the person in the process of adjustment. He tries to unravel the

essential drives beneath the superficial manifestations, and to see the

purpose of these symptom formations in the living economy of the patient.

n 3 o PERSONALITY AND THE BEHAVIOR DISORDERS [34

As the psychiatrist discovers the patient's typical patterns of adjustment,

he translates his reading of various situations to the patient. This type

of therapy is more effective, but it requires more skill and contains more

possibility of error. It has its uses and its values, but the more the

physician allows the patient the opportunity of making his own interpre-

tations and merely helps him guard against rationalizations and faulty

reasoning in general, the more sure will be the ground on which he

helps the patient to stand.

Even in explanatory, expository, or interpretative therapy, the inter-

view need not be formal and directed. The patient must feel free to talk

of anything that comes to mind. Even if this delays the discussion of

something the patient has read, it can be brought up at the end of the

hour or at a later conference. It is important for patients to develop

initiative and self-expression, and holding too close to something that

was planned tends to dampen this self-direction.

Two of the most difficult problems in psychiatry are, when to try to

explain, and when to support and help. Premature explanation falls on

deaf ears, psychological blind spots, and defensive thinking. It may arouse

intense resistance, evasion, and resentment. It may take away initiative,

responsibility, and practice in exploration, reflection, and achievement,.

As such, therapy may be actually retarded, even though the goal is con-

sciously the reverse. Much the same holds for giving advice, making

decisions for the patient, and offering support and help.

Bibliotherapy is the use of books, articles, pamphlets, etc., as adjuvants

in psychiatric treatment. Patients may be asked to read printed matter for

a number of reasons. It serves chiefly as a means of acquiring information

and knowledge about the psychology and physiology of human behavior.

The references for this section (see special section in bibliography) give

more information than it is here possible to consider. Menninger (1937)

has an article discussing the psychological values in the use of biblio-

therapy. A pamphlet by Mudd and Whitehill (1938) discusses its use

in the premarital interview and sexual and marital adjustments. Ingram

(1939) has many practical suggestions, not only for its use in private

practice but for hospital practice as well. Twyeffort (1940) gives a

general survey of the field and a most useful bibliography which will

help the physician in his search for tried and practiced books. Bradley

and Bosquet (1936) have published an article on the "Use of Books

for Psychotherapy with Children" in which reading lists are given.

In psychiatry reading may be recommended to enable the individual

to live up to the injunction "Know Thyself/' Reading may be advised

in an attempt to extravert the patient and arouse his interest in some-

thing outside himself. Other purposes may be to arouse interest in and

acquaintance with external reality, or to effect a controlled release

(abreaction) of unconscious processes, or to offer opportunities for iden-

tification and compensation. Of course, it is used to help the patient

develop a clarification of his difficulties and contribute to the develop-

ment of "insight" into his condition. It is also an attempt to implement

34] PSYCHIATRIC THERAPY 1131

the experience of others in effecting a cure. Reading supplements not

only the knowledge and experience of the therapist, but it extends the

period of the therapeutic conference, when the patient cannot be seeing

the doctor. Its final aim is to aid the patient to live more effectively.

It is an advantage if the patient asks the physician if there is not some

reading matter which will be helpful to him. Self-motivation usually

means that the reading will be done more thoughtfully, conscientiously,

and zestfully than if it is merely recommended by the physician. The

particular book or articles recommended depend on many things. The

most important are the educational and therapeutic needs of the patient,

the type of person (e.g., whether a normal, healthy person seeking

desired information, or a patient with a neurosis or psychosis), the edu-

cational background and intelligence of the individual, and the cultural,

religious, and social background. The prescription of reading matter

must be a highly individualized procedure if it is to be successful.

The order of psychiatric reading which we have found most effective

follows. Osier's Way of Life (1932) is perhaps the most useful intro-

duction we know. It is not written primarily for patients with nervous

or mental disease, and it does not contain psychological and psychiatric

terminology ; nevertheless, it enables the patient to breathe an atmosphere

of essential mental hygiene. It also offers a wholesome philosophy of life

by an eminently successful man. The problem of living is simplified with

a few plain and essential rules. This is especially helpful because patients

have been thinking of so many complicated things and worries that it is

a relief to get something brief, clear, authoritative, and hopeful.

Riggs' little book Just Nerves (1922) is an excellent one to follow

Osier. It is also brief, the introduction is simple and it makes the psy-

chology of nervousness easily understood. The last chapter on ele-

mentary rules for mental health (to which patients quickly turn) is again

clear and inspiring. It contains sense which the patient recognizes. At

the same time he realizes that some of these rules apply to him. He

feels a sense of discovery and achievement, and that there is something

definite on which to stand and build.

Discovering Ourselves (1931) appropriately comes next. This book

is written in simple nontechnical language so that a person with mid-

high school background can understand it. The chapters are for the

most part brief and do not require prolonged periods of concentration.

Technical and pathological terms are not employed but normal mental

processes are described from the dynamic point of view. Extreme diffi-

culties of thought and behavior are interpreted as intensifications and

exaggerations of normal processes, rather than as morbid deviations and

distortions. We have used the book not only to acquaint the patient with

dynamic psychological processes, but also to stimulate in him the chal-

lenge to discover his own difficulties and take the initiative in trying to

solve them.

When a patient has finished reading Discovering Ourselves, he is

aware of the importance of childhood experiences and parental relation-

n 3 2 PERSONALITY AND THE BEHAVIOR DISORDERS [34

ships. He may begin to discuss sex problems and sex education. Criti<

cism of his own social and sexual education come to the fore. At this

period we have found Sayles' The Problem Child at Home (1928) prob-

ably the most satisfactory book. The chapters on mistaken ideas which

influence the development of children reinforce and clarify the patient's

critical faculties. They afford an outlet for resentments and aggressions.

The next transition is often made to Thorn's Normal Youth and Its

Everyday Problems (1932), or Frankwood Williams' book (1930) on

adolescence. When family relationships are factors of importance in the

development of nervousness, the discussion in Levy and Monroe's book,

The Happy Family (1941), has been found most helpful. Then, if

further emphasis on family education and on adolescence does not seem

to be indicated, Horney's The Neurotic Personality of Our Time (1937)

is given. This offers a clear and impressive discussion of the mechanisms

of neurosis in the individual, and also emphasizes the cultural forces at

work especially through the parents. A historical perspective is then

added with Robinson's Mind in the Making (1921). This not only

reviews our animal heritage but the various kinds of thinking that get

not only individuals but civilizations into trouble. A note of optimism

with a historical perspective may be added by Edman's Candle in the

Dark (1939).

This reading, of course, is not a cut-and-dried and formal process.

Part of the interviews has to be given over to a review of the interval

history and presenting problems that have developed. Reviews of the

past history of the individual are naturally discussed and they are

abreacted in response to what has been read. Some interviews may

scarcely get round to the consideration of reading matter at all. The

procedure should be as spontaneous and flexible as possible. Some con-

ditions may make it advisable to alter the order and selection of books.

Bibliotherapy, then, we believe, has a definite place in practical psy-

chiatry. Its value has probably in general been underestimated. There

are very few studies of its use in the literature. Its greatest advantage

is time saving. We have found in many instances that therapy went ahead

much faster with its use than with those patients who had not done any

reading. Besides giving knowledge and information, another advantage

lies in the fact that it familiarizes the patient with terminology and with

the accurate use of words. This is not to be overlooked because so many

people use terms so loosely, and the use of words is especially difficult

in psychology and psychiatry because they deal with abstractions. Such

reading introduces the patient to the conception of objectivity and helps

him acquire a broader view of human nature. It can present the total

picture of mental functions or mechanics much more clearly and com-

pletely than one can by the question and answer technique. It also

removes the personal factor. It often enables the patient to discover

things for himself instead of having them pointed out by the therapist, or

having to take things on his authority. It helps in relieving a sense of

isolation from which so many patients with neurosis suffer. It relieves

34] PSYCHIATRIC THERAPY 1133

them to discover that many others have had the same (often common and

even normal) difficulties.

Notwithstanding these many advantages, there are many disadvantages

and limitations to bibliotherapy. Many people have not been in the habit

of reading or cannot read ; many others will not. Some do not have the

intellectual ability to read understandingly and the majority of nerv-

ously ill patients are unable to read because of the psychological disturb-

ances inherent in their neuroses. It is unfeasible to get the majority of

patients in mental hospitals to read but there is still a large group for

whom reading is advantageous and there is certainly a large proportion

of patients in office practice for whom it is beneficial.

Personality Study. In the last quarter century psychiatry has

shifted its interest from detailed descriptions of nervous and mental con-

ditions and precise classification, to an understanding of developmental

and etiological conditions. Psychiatrists are not so much interested in

symptoms and attempts at refined nosological demarcations ; they are

satisfied with general reaction types. The important things are the

dynamics of the various conditions. This dynamic or developmental

approach has been instigated and fostered by the great men of recent

psychiatry. Among others are Freud, Adler, Kretschmer, Hoch, Meyer,

and Strecker.

One of the most satisfactory ways, not only of gaining an understand-

ing of the individual and of the condition from which he is suffering, but

also of giving positive therapy is the personality study. Systematic study

of personal development not only brings into relief the forces at work

in the present personality, but, inevitably, discussing them brings to light

important etiological considerations.

It may well be asked what a scheme for personality study has

to do with psychotherapy, and the answer lies in the fact that therapy

in psychiatry (exclusive of medical, toxic, infective, and exhaustive con-

ditions) is different from that in medicine. Treatment, in medicine, is

a separate procedure from the history taking, and the physical and lab-

oratory examinations of the patient. In psychiatry, on the contrary, the

study of the patient's personality and the exploration of its development

has a distinctly beneficial therapeutic influence. The questions at once

stimulate the patient to take new and wholesome attitudes towards his

condition. He often comes wanting help and advice; he often is ready

to submit to the authority of the physician as a child to its loved parent.

His responsibility is shifted completely to the physician ; he wants to be

worked upon as by magic, very much according to his conception of the

way the surgeon works. This is not the wholesome way in psychiatric

therapy. The physician's questions show indirectly that all is not as sim-

ple and clean-cut as the patient is inclined to think. There is more to his

condition that needs consideration and treatment than just the symp-

toms, which are not as important as he thought they were. He is thus

jiecess.arily initiated into the wholesome process of objectivity. Other

H34 PERSONALITY AND THE BEHAVIOR DISORDERS [34

relevancies than those he had considered must be gone into. Such pro-

cedure gives the patient something to do, "a bone to chew on." Instead

of feeling helpless and passive, he learns there is something that he can

do and is expected to do. He is challenged with the hope of a new

attack on his condition of hopeless passivity and suffering. The more

informal, casual, and drawn out in time (weeks or months if necessary

or advisable) this process is, the more therapeutic value it will have.

Casualness, equanimity, and lack of haste, exude a therapeutic strength

which helps reduce the intensity of the patient's feelings. It helps to

dissipate insecurity and fear, and is of inestimable value compared with

formality, overseriousness, and professional terminology.

Amsden (1923) has published a satisfactory scheme of personality

study, and we have worked out one that was originally published in a

book on the examination of patients (Appel and Strecker, 1936). The

first area investigated is physical health, with questions as to illnesses,

operations, etc., and what part these have played in the life history. From

this it is an easy transition to the concept of energy. Has the individual

been overactive with excess of energy or is he tired much of the time?

From the consideration of energy, it is an easy step to observations con-

cerning whether the individual is usually calm or tense, and how his

temper has affected him vocationally or socially. From this, one turns

readily to the other emotional reactions, with social situations coming

quite naturally next. Is he an outgoing, active, friendly type of person

with lots of friends, or a cold, distant person whom one gets to know

with difficulty ? The next group of questions relates very much to self-

confidence and the super-ego. Is he decisive or indecisive, is he cocky

and dogmatic? Is he submissive or a fighter, etc. Is he dependent or

independent? Upon what is he dependent? What are his standards?

his goals ? It is important to go into the patient's development, and he

can be asked what he has heard about his mother's condition when she

was pregnant; about his birth and early training; about his childhood

fears; about his sexual training and how he felt about this; about his

parental relationships (identifications and antagonisms).

Sometimes such an outline will apparently be curative, but at other

times it will completely fail therapeutically. Generally, it gives the

patient hope that there is something to discover that will help him out

of the trouble, and this hope is one of the greatest therapeutic tools.

There are many disadvantages to such a system. It is apt to become

too formal. Free association is not provided for, but practically, a certain

amount can be cultivated by allowing the patient plenty of time, by letting

his conversation drift where it will, and by not guiding it too much with

questions. One great objection is that unless a considerable amount of

free association is encouraged, the patient does not learn to know his

unconscious patterns. The transference and resistance are not tackled.

It cannot be used with any but the mildest psychotics, and with severe

neurotics it is often therapeutically ineffective. When the patient gets

talked out and the ordinary psychiatric interview is making no progress.

34] PSYCHIATRIC THERAPY 1135

however, the personality study can be used. When this is exhausted, one

can proceed to a form of bibliotherapy, or to modified analysis. This

method is a short-cut, a compromise, necessitated at times by certain

inevitable exigencies.

Psychoanalysis. HISTORY. Charcot demonstrated the dynamics ol

ideas in hysteria. He showed that ideas caused such symptoms as the

paralysis following emotional shock. Furthermore, ideas, or instructions,

given in hypnosis can produce similar symptoms. Liebeault and Bernheim

disclosed the rationalization of motives in their studies in hypnotism.

Janet, working with hysterical conditions at the Salpetriere under

Charcot, found that hidden memories were important in the develop-

ment of such neuroses. They were either memories of actual traumatic

incidents or of events associated with some moral perturbation. These

memories dissociated themselves from the main trend of consciousness by

the process of "psychological automatism" and became subconscious

"idees fixes." By the discovery of these memories, a discussion of them,

and by a process of moral liquidation or assimilation, of conscious reason-

ing, and of stimulation and direction, cure was effected in many cases

(see Janet, 1889).

Freud (see 1910 and 1914) studied with Charcot in Paris and learned

from him the dynamics of ideas in hysteria. He visited Bernheim at

Nancy and got from him the post-hypnotic rationalization of motivation,

and also the fact that by special effort the patient could discover the real

motive. He was familiar with Janet's work on the effect of memories in

traumatic hysterical contractures. When he returned to Vienna he col-

laborated with his friend Breuer who had been studying hysteria under

hypnosis. In 1893 and 1895, they published their now famous report on

cases of hysteria. In these they concluded that hysterical phenomena are

caused by ideas to which strong affect has been attached. They believed

a disturbance in associations takes place similar to that in sleepiness, in

which unusual associations are formed, and the affect jumps, as it were,

into abnormal physical and mental paths producing the various phe-

nomena of hysteria. They brought about cure by bringing to conscious-

ness these various memories or reminiscences accompanied with their

usual emotion or excitements. This expression of pent-up affect along

with the appropriate idea they called abreaction, and the process they

called catharsis. The patient was said to suffer from reminiscences, and

the essence of their cathartic therapy was to discover the traumatic

events which were originally painful to the patient, and to bring them to

consciousness with appropriate expression of emotion by getting the

patient to talk about them during a hypnotic trance. This procedure

freed the patient from symptoms.

Freud soon abandoned hypnosis as part of his procedure, however,

because many patients could not be hypnotized and he was able to obtain

results from his talking treatment without hypnosis. He asked the

patients to speak of anything that came into their minds and did not

1136 PERSONALITY AND THE BEHAVIOR DISORDERS [34

insist on their recalling special experiences related to their symptoms.

He found that finally they came of their own accord to thoughts, experi-

ences, and phantasies, that had been important in their lives (see also

Chapter 7 by French and Chapter 21 by Ribble).

Because an emphasis on sex developed in psychoanalysis, and because

patients apparently fell in love with the analyst, Breuer withdrew from

his collaboration with Freud. Freud persevered and began his analysis

of this falling in love from which he found that the physician was a sub-

stitute for someone the patient had previously loved. This was the begin-

ning of his studies of the mechanism of transference (see Freud, 1914).

Freud then formulated the hypothesis of the unconscious ; that there

are forces, inclinations, influences, impulses, attitudes, of which the indi-

vidual is unaware but which modify unwittingly his conscious thinking,

preferences, antipathies, and behavior. These unconscious forces he be-

lieved were especially important in the psychoneuroses and functional

psychoses. In his investigations in hysteria, he found that many symp-

toms were apparently symbolic expressions of ideas which were once

conscious but which because of their painful character had been repressed

or forgotten, and remained below the threshold of awareness or con-

sciousness (Freud, 1896). These ideas or impulses were still active,

however, and they influenced consciousness and behavior even though

the patient was unaware of this influence. There appeared to be a resist-

ance against bringing these unpleasant or painful thoughts or remi-

niscences to consciousness. He discovered that this resistance belonged

to the same set of personality factors which caused the repression. As

the patient talked freely, not infrequently dreams were related. Grad-

ually it developed that elements of the dreams appeared to be related

not only to the present life and problems of the individual, but to the

symptoms of the patient, and also to his past in this other "subliminal"

aspect of the personality which Freud called the unconscious.

It appeared that dreams had a language of their own and a psychol-

ogy that was similar to the psychology of functional symptoms. As a

result of these observations and conclusions, Freud (1900) published his

Interpretation of Dreams. Dreams are said to be the royal road to the

unconscious. They represent the fulfillment of a wish. Their function is

to preserve sleep. Thoughts and impulses that are hidden or rejected

press forward in phantasy, disguised in symbols so that they may be

more acceptable to consciousness. Free associations, letting the mind

wander over the various elements of a dream, bring meaning to it usually.

However, it is true that there are dreams which even the most experi-

enced analysts cannot clarify (see also Freud, 1904, 1905).

There are great differences in the way various analysts help patients

to find the meaning of their dreams. There is a contrast between active

and aggressive interpretation on the part of the analyst and the tech-

nique of remaining passive, suggesting no interpretation, and allowing

the patient, through his own associations to arrive at an understanding

of the significance of the dream himself. This latter technique seems to

34] PSYCHIATRIC THERAPY 1137

me to be on much more solid ground, psychologically, than the aggres-

sive type of interpretation. It enables the patient to assimilate his own

thoughts and associations, instead of having to accept the thoughts of the

analyst which may seem alien to him. The self-made interpretations, in

my experience, enable the patient ultimately to see more satisfactorily the

relevancy of tendencies for his own personality and problems.

THEORY OF THE DISORDERS. That certain types of neuroses and

psychoses have patterns of activity, and of associated thinking and feeling

which are similar to those found in various periods of growth, is one of

Freud's discoveries (see Chapter 7 by French). Stimulation, frustration,

prolongation of these activities in the various stages of growth, he be-

lieved, determined the development of the various types of neuroses.

Thus Freud, Abraham, and Fenichel developed correlations between

dominant fixation points in the course of development, and common clin-

ical conditions. There is a correlation between the various disorders and

the patient's effectiveness in dealing psychologically with objects. For

example, in extreme schizophrenia there is no object of interest or

love in the external world. In hysteria there are interests or loves but

adult genital interests are excluded. In schizophrenia, particularly in the

extreme degrees, the patient lives on the sucking stage of existence. In

manic-depressive psychoses, the thoughts and words of the patient are

shot through with oral symbols. In the compulsion neuroses, hate is

expressed in anal symbols. For a brief account of these stages see

Chapter 21 by Ribble, and for an extended account of clinical psycho-

analysis see Fenichel (1934).

Since psychoanalysis has developed a nomenclature that is somewhat

different from that of the traditional psychiatric classifications, one must

be able to translate the terms of one classification into those of the other.

The following are some practical translations or equivalents. Hysteria

in the traditional classification is represented in psychoanalytic termi-

nology by anxiety neurosis, conversion hysteria, and anxiety hysteria.

Neurasthenia in the classical tradition is represented in psychoanalytic

classification by both neurasthenia and conversion hysteria. Psychas-

thenia in the usual classification includes two conditions in psychoanalysis,

namely, anxiety hysteria and obsessional-compulsion neurosis. If the

term "anxiety states" is used, it probably includes psychoanalytically,

anxiety neurosis, conversion hysteria, and anxiety hysteria. For the

various psychoses psychoanalysis employs the usual terms.

It is considered practically indispensable in order to practice psycho-

analysis that a physician be analyzed himself. After this, in order to be

certified he must analyze a number of cases under supervision.

THE TECHNIQUE OF PSYCHOANALYSIS. A thorough history is

taken. It is important to have a report from another physician as to the

physical health of the patient. Psychoanalysis classically teaches that

the analyst should make no physical examination of the patient nor treat

him medically. It is felt that the effect of such examination and treatment

1138 PERSONALITY AND THE BEHAVIOR DISORDERS [34

arouses emotional reactions in the patient which interfere with satis-

factory therapy. Schilder disagrees with this opinion. A regular psy-

chiatric examination, however, is made, including an examination of the

patient's family history, his parent and sibling relationships, his educa-

tional history, his vocational, social, and mental history. This is im-

portant, of course, not only for diagnostic purposes, but to determine

whether it is possible or wise to analyze the patient.

In psychoanalytic procedure, the patient reclines on a couch in a

semi-darkened room. The analyst sits behind him. The purpose of this

is to remove all external stimuli as far as possible, so that the patient may

remain as relaxed as possible and concentrate on whatever comes spon-

taneously to his consciousness, and so that the only contact of patient

and analyst is conversational. He is simply told that he is to talk of

everything that comes before his mind's eye. I usually explain to the

patient that he has already discussed his symptoms and life from the

ordinary logical point of view, and that he has already answered ques-

tions directed to him by physicians with certain focal points of his life

and illness in view. I then tell the patient that I want to observe and to

help him observe his undirected thinking. We want to see what thoughts,

feelings, and impulses come spontaneously to mind without direction. We

want to observe his undirected, spontaneous, automatic thinking. He is

told, furthermore, to let his mind wander, to talk of everything that

occurs to him, to be passive, and to talk just as he would speak ot things

that crossed his visual path were he sitting in a railroad train. There,

too, there are rapid shifts, and different things appear in no coherent

order. No matter how irrelevant, how foolish, how illogical, or how

unpleasant the things are which come to his mind, he is to speak of them

all. Nothing is to be held back. Nothing is to be consciously rejected or

selected. Of course, he may discuss and comment on anything that comes

up. Religion, art, philosophy, morality, resentments, hates, fears, hopes,

ideals ; everything is grist for the mill. This is the method of free asso-

ciation which Schilder (1938) has called "the most important technical

development in modern psychotherapy/' This is clearly different from

the usual conversational procedure of psychiatrist and patient. There the

physician is usually very active, asking questions, directing attention, and

taking the lead in reasoning and explaining. In psychoanalysis, on the

contrary, the doctor remains passive and the patient is active.

The stream of consciousness relieved of social, rational, and aesthetic

directions shows a definite drift in the long run. Thoughts, feelings, and

desires appear and recur with a frequency and emphasis that convince

the patient that there are forces at work within his personality that are

important for him in his difficulties and in his life. New sequences, cor-

relations, and relevancies emerge. These processes throw new light on

his personality and its problems. By virtue of these he sees himself in

a new perspective. There is scarcely any other relationship in life that

allows a person continuously to speak so freely. Even the confessional

does not afford this. The capacity to express even hate and resentment

34] PSYCHIATRIC THERAPY 1139

without being criticized and condemned helps not only to abreact (and

sometimes reject) these feelings but also to obtain a mastery of them.

The ability to express feelings, phantasies, impulses, and reactions which

one scarcely ever has put into words is of therapeutic value. It is a first

step in dealing with them and laying hold of them. And the communica-

tion of them in words to another human being is to step out of the world

of privacy and isolation into a world of objectivity, that is, of reality.

The fact that the analyst is there and is not shocked, not fearful and not

critical, gives him an example perhaps of a capacity in another human

being to meet chaos, suffering, tragedy, difficulties, fear, anger, and the

more elemental and primitive sides of human nature without becoming

upset. The suggestive element in merely accepting the patient for treat-

ment, as a human relationship, is clearly present.

But psychoanalysis passively conducted is the form of psychiatric

treatment in which the least suggestion enters. It is the psychoanalyst's

ideal to make no suggestions, but merely to help the patient (by his

questions) face his own problems, accept his own impulses, take respon-

sibility for them, and work out gradually a more satisfactory adjustment.

Of course, it is possible in one's tone of voice and by the questions asked

to use suggestion. But by a neutral expression of voice and careful atten-

tion to the questions, it is possible to reduce suggestion to a minimum.

No advice is given, which, of course, is against a dominant desire of the

patient, unless there is an acute psychiatric or medical emergency, and,

in the latter case, it is considered most desirable to turn the patient imme-

diately over to a medical consultant.

Ferenczi and others have introduced more active methods, at times,

especially in compulsive states. They force frustrations. Or if an extra-

marital or homosexual relationship is interfering with the progress of the

analysis, it is interdicted. But in straight analysis these departures are

not used. Thus the analysis can be very objective, and the contribution

of the analyst can be reduced to a minimum except in giving help by

asking relevant questions. The patient develops a sense of responsibility

for his mental processes and sees the meaning of them in his past experi-

ences. He is also stimulated to take an active part in dealing with them.

Meaning gradually emerges from the meaningless ; relevancy appears in

irrelevancies ; order, sequence, and correlation appear in the chaotic.

Connections (associations) that have been broken up or separated (for-

gotten or repressed, dissociated) become reconnected (reassociated).

Mental elements that had appeared isolated, insignificant or meaningless,

acquire significance. In this new experience of free association and in

this relationship with another human being whose chief tools are silence,

questions, and help in interpretation, a new understanding and a new

personality develop. And just as slips of action and speech (see Freud,

1904), dreams and phantasies take on meaning, so do symptoms, and

they often disappear even when they have proved intractable with other

methods of therapy.

The usual period of analysis is 50 minutes. Classically, there are six

1 140 PERSONALITY AND THE BEHAVIOR DISORDERS [34

sessions a week, but for certain practical reasons this may be reduced to

once a week or several times a week. Once a week, however, is usually

too infrequent because too much time is taken up with the mere chronol-

ogy of events. There is no time limit for an analysis. It may take from

several months to several years. The latter is not surprising, however, in

severe cases, when one remembers that it takes five or ten years to make

a reasonably social being out of the average infant, and that patients may

have gone 20 or 30 years with their habits of unsatisfactory adjustment.

TRANSFERENCE. Emotions that the patient needs to express are pro-

jected onto the analyst. This is the process of transference. Freud writes :

If the patient is to fight the normal conflict that on analysis is

revealed against the suppressions, he requires a tremendous impetus

to influence the desirable decision which will lead him back to health.

Otherwise he might decide for a repetition of the former issue and

allow these factors which have been admitted to consciousness to

slip back into suppression. The deciding vote in this conflict is not

given by his intellectual penetration which is neither strong nor

free enough for such an achievement, but only by his relation to the

physician. Inasmuch as his transference carries a positive sign, it

invests the physician with authority and is converted into faith for

his communications and conceptions. Without transference of this

sort, or without a negative transfer, he would not even listen to the

physician and to his arguments. (1920)

The patient must work through his transference. A negative trans-

ference can be just as effective a tool of therapy as a positive one. Grad-

ually he learns that he has been adopting attitudes toward the analyst

which he held toward persons important in his early environment. This

is inappropriate, subjective, and unrealistic. Gradually he works through

this and is able to develop new and more appropriate attitudes, not only

toward the analyst but toward other persons in his present environment.

The control which the patient projects on the analyst through identifica-

tion or rejection, he gradually learns belongs to himself.

Schilder (1938), in a chapter on the relation between physician and

patient, presents one of the clearest and most illuminating discussions of

which we know. It should be read by all psychiatrists. His most impor-

tant points are as follows. There are three aspects to the transference,

viz., winning the transference, working it through, and breaking it. The

more passive the analyst remains, the less he exhibits his own opinions

and ideas, the more readily the transference will develop. The trans-

ference is not made by the physician ; it is developed by the patient. If a

negative transference does not appear, the analysis will remain super-

ficial. The passive, masochistic attitude of the patient may provoke an

aggressive attitude on the part of the analyst, which may contain erotic

components. The analyst's narcissism may be stimulated, he must watch

it, for he may overrate himself as he is so accustomed to play the superior

role. Perfectionist desires on the part of the physician must be watched

34] PSYCHIATRIC THERAPY 1141

lest they make impossible demands on the patient. The physician may

react to the immature wishes of the patient, by exhibiting infantile atti-

tudes himself, viz., the wish for absolute authority over the patient and

the desire for the latter's implicit compliance. He warns against a too

rigid technique. "Be human and respect the personality of the patient."

He makes the further point that freedom from symptoms is no criterion

of cure, it may be the result of the transference relationship.

The transference neuroses (conversion hysteria, anxiety hysteria,

compulsion neuroses) are the conditions most suitable for psychoanalysis.

The actual neuroses (anxiety neurosis and neurasthenia), since they are

caused by defective sexual hygiene in the present, are treated with ade-

quate sexual instruction. Psychoanalysis is indicated in the perversions,

especially in homosexuality and in compulsive autoeroticism. It is help-

ful in marked psychoneurotic additions to certain types of somatic dis-

ease. The new emphasis on psychosomatic medicine is, of course, a fruit-

ful field for psychoanalysis. In some cases of character disorder, and of

vocational and marital failure, psychoanalysis is beneficial. Disorders

of the sexual life such as impotence, premature ejaculation, and frigidity

in some cases are greatly helped or cured by it. Prepsychotic personali-

ties and prepsychotic conditions often obtain great benefit, and it is felt

that sometimes a psychosis is obviated. In the remissions of manic-

depressive insanity and schizophrenia, it is occasionally of benefit. A

modified kind of analysis has proved distinctly helpful in a number of

cases of paranoid conditions in our experience. It cannot be used, how-

ever, in the acute and chronic stages of the narcissistic neuroses. It used

to be said that psychoanalysis was not to be recommended in the psy-

choses. This rule holds in general, but, as pointed out above, in the pre-

psychotic stage of a malignant psychosis, in the remissions of psychosis,

and in certain mild types of malignant psychosis, in selected cases, it can

accomplish a great deal.

Psychoanalysis is not successful with patients of an inferior or defi-

nitely limited intelligence. It is not applicable in conditions with organic

brain disease, e.g., arteriosclerosis, syphilis, and the toxic, infective,

exhaustive psychoses. Patients who do not come for treatment of their

own free will are not suitable subjects. Uncooperative patients, of course,

cannot be analyzed nor can those who do not desire recovery. Those

lacking a certain stage of ethical development, e.g., psychopathic person-

alities, are not fruitful subjects, and those who cannot afford to pay

something at least do not usually do well. Patients with marked pain

are not satisfactory subjects, nor are faddists or dilettantes. It is usually

stated that in patients over the age of fifty years psychoanalysis is con-

traindicated.

MODIFICATIONS OF PSYCHOANALYSIS. Klein (1937), Anna Freud

(1928), Aichorn (1936), and Susan Isaacs have applied psychoanalysis

especially to behavior problems and difficulties in the development of

children (p. 1149).

H42 PERSONALITY AND THE BEHAVIOR DISORDERS [34

The Swiss physician, Jung, followed Freud for a time and was a leader

in the psychoanalytic movement. Later his views diverged so much that

he founded an independent school of thought called Analytic Psychology

(Jung, 1916). His chief contributions have been: studies in the asso-

ciation experiment, the psychology of dementia praecox, a broader con-

cept of the racial unconscious, the psychology of personality types, the

concepts of the persons, the animus and the anima, studies of artistic

creation, investigations into mythology, folk lore and religion and their

relation to dreams, phantasies, neuroses, and the cultural strivings and

conflicts of the individual. In addition he stressed a synthetic emphasis

in therapy. His studies in the word-association test laid a sound foun-

dation for the psychology of free association. He showed that there was

a psychology of dementia praecox, and that earlier experiences had an

influence on the development of the psychosis, and in these studies he

did pioneering work in the foundation of psychopathology (see the sec-

tions on Association in Chapter 6 by White and Chapter 33 by Hunt

and Cofer).

Jung emphasized the creative and prospective possibilities of man

more than the erotic, infantile, egoistic impulses which Freud studied.

He is more teleological, creative, and future-looking in his emphasis than

was Freud. Jung has pointed to the mother as a creative symbol. Freud

pointed to the father as a source of control (castration complex), a factor

in social organization, and an object of hate and aggression. Libido for

Jung is not merely the sexual impulse with its ramifications ; for him it

is life energy, allied to Bergson's elan vital. Part of the libido, he be-

lieves, has been dissexualized through ages of adaptation to reality.

Universal meanings and their images (archetypes) are searched for

by Jung, rather than the particular experiences sought by Freud. If

personal "associations'* cannot be found in relation to mental images,

they are held to be of archetypal origin. Man in searching for his goal

relates himself to the Logos, the essential masculine principle. He is

apt to ignore the recognition of the anima or feminine principle in his

unconscious. Woman's principle of life is Eros and her difficulty is relat-

ing herself to the masculine Logos.

Man contains a racial unconscious which for Jung seems to be more

important than the personal unconscious. As the instincts are to the

organism, so are the archetypes or racial unconscious to the mind. Psy-

chological instincts or forces of thought common to all people are inher-

ited, as part of the experience of the race. They are ancestral interpre-

tations of experience, i.e., primitive, primordial explanations of the

forces of nature and human relations.

The therapy of Jung is directed toward an elucidation of the tenden-

cies in the unconscious. One must learn to understand one's patterns as

represented in universal symbols. The patient must learn the difference

between his conscious tendencies and the unconscious urges struggling

for expression.

Adler's studies and therapy have been concerned chiefly with the ego,

34] PSYCHIATRIC THERAPY 1143

and its fundamental strivings and mistakes (Adler, 1907, 1909, 1923).

The paradigm of Adler's formulations briefly is the following. Bodily or

organ inferiority will to power > compensatory reactions :

masculine protest = neurotic symptoms. The helplessness of the infant,

the smallness of the child, and some weakness of a bodily organ pro-

duces insecurity. This stimulates his strivings to overcome this handicap.

The chief striving Adler emphasizes is the will to adequacy or power.

Urges to assert oneself, to excel, to be superior, and to defend oneself

then develop. Aggressive or escape tendencies to win security or power

are the mechanisms of this striving. These compensatory activities

are subsumed under Adler's term masculine protest. The individual

(whether masculine or feminine) wants to be a man, have power, like

fathers. The various psychological processes (rationalization, phantasy,

asocial behavior) developed to maintain this fiction and to deny one's

weakness and inferiority are the symptoms patients complain of in neu-

rosis. Such a paradigm, according to Adler, lies beneath every neurosis.

Inadequacies and inferiorities overemphasize the drive to succeed and

to excel. Suppose one's ambitions cannot be fulfilled. Unwilling to admit

defeat, the individual denies his lack of success and his inadequacies,

protects his self-esteem, wins substituted power and satisfaction in neu-

rosis. He then lives as though he were ill, gets satisfaction out of his

fiction, makes the demands of real illness upon his relatives and friends,

emphasizing demands and rights but not duties or obligations. His strat-

egy of life, his "life pattern/' is mistaken.

Therapy consists essentially in discussing these mistakes of his life

pattern and straightening them out in friendly discussion. A protracted

questionnaire of the patient's life history is taken. The life pattern is

crystallized early in childhood or infancy. Family relationships, thus, in

addition to organ defects, are important etiological influences. The place

in the family is important. The eldest child is overvalued. His parents

look upon him as an extraordinary and delightful gift from heaven. He

absorbs this pattern and acts it out in life. His "will to power" is exag'

gerated. The second child, of course, feels his inadequacy in comparison

with this extraordinary first child and is very apt to compensate for this

with aggressiveness. The youngest child may be spoiled, feel rejected,

or very small and inadequate, and personality characteristics to compen-

sate for this develop. The only child, of course, is spoiled with an inordi-

nate amount of attention and concern. He becomes narcissistic and

conceited. He has an exaggerated attitude of his own capacities

(omnipotence) and the consideration others should show him. Achieve-

ments and rewards are desired without the necessary effort. He reacts

or compensates with the fiction that people do not appreciate him and are

unfair to him.

There is always an optimistic note in Adlerian teaching. The patient

is told he has the capacity to learn the nature of his failures and mistaken

patterns and achieve a change. Beran Wolfe has succinctly and popu-

larly formulated Adlerian doctrines (Wolfe, 1931. 1933). Therapy is a

1 144 PERSONALITY AND THE BEHAVIOR DISORDERS [34

process of education, enlightenment, discovery, and encouragement.

Conscious discussion, training, and suggestion from the therapist will

enable the patient to overcome his sense of inferiority and develop a

normal personality.

Many criticisms of Adler's psychology and therapy can be made. The

force of reason in human behavior is greatly overemphasized. Adlerian

psychology seems to suffer from the rationalist's fallacy, that because

reason can discover the sources of mistakes, and can unearth sequences

and correlations, reason has produced them. Irrational forces are mini-

mized and do not receive adequate consideration. Patients frequently

get the impression in reading Adlerian literature that their actions have

been deliberate. They feel that the interpretations in therapy are a slur

on their characters, that they have been cowardly, and that they have

been dangerously near fraud and malingering. It almost assumes that

the patient knows his mistakes and has deliberately chosen to escape and

avoid them. In Adlerian therapy there is a great tendency to force the

therapist's interpretation or point of view on to the patient and to con-

vince him.

Nevertheless, Adlerian conceptions have had a great influence in psy-

chiatry. They are therapeutically similar in many ways to the methods

of Meyer and Riggs. Adler's formulations are simple and straight-

forward. They are easily understood. They are reasonable and can be

used beneficially when for a number of reasons it is impracticable or im-

possible to employ deep therapy or psychoanalysis. Adlerian conceptions

are helpful to parents in considering their children's difficulties. They

do not frighten parents or child as do psychoanalytic concepts at times.

The terms are those of everyday speech, while Freudian terms are spe-

cialized and at times esoteric. The social and educational influence of

Adler has been great and beneficial ; his therapy has proved most useful

in the guidance of children and in the treatment of the milder psycho-

neuroses and personality difficulties.

Dynamic Growth Therapy. For want of a better name, dynamic

growth therapy is the term we have given to an eclectic therapy in which,

at the proper time, all of the various techniques of treatment may be

employed. With tact, sympathy, kindliness, encouragement, and without

crippling criticism, the psychiatrist endeavors to help the patient develop

a constructive healthy personality. In the philosophy of this therapy, the

importance of all functions is recognized and used : intellect, habit, action,

emotion, instinct, will, social influences, and ideals. In this type of

therapy, the psychiatrist establishes a constructive human relationship

with the patient wherein he accepts the patient as a person and gives

support, encouragement, and understanding. He may use the values of

practice in action. He recognizes the value of inspiration derived from

enthusiasms and social ideals, the value of abreaction, and the value of

direction. General educational principles are employed, and the concept

of growth is stressed. The patient becomes a new individual, with new

34] PSYCHIATRIC THERAPY 1145

capacities, and he is freed from the crippling attitudes and habits of his

past.

Dynamic growth therapy, being eclectic, can use psychoanalysis or

psychoanalytic concepts, as any therapy at the present time is bound to

do. But it is not exclusively psychoanalytic. The necessity of helping

the patient understand the dynamic relationships between his past expe-

rience, his training, his attitudes, his urges, on the one hand, and his

difficulties and symptoms, on the other, is one of the most fundamental

processes in psychotherapy. Whether this comes from a deliberate exer-

cise of free association, or from free association in more informal con-

versation, in bibliotherapy, or in personality study, it is necessary for

adequate psychotherapy. Dynamic growth therapy is not exclusively

emotional. It is not essentially intellectual. It is minimally authoritative.

It uses all the approaches to understanding and developing personality.

We believe that much psychiatric therapy has fallen down because it was

too one-sided. Too many therapists have been devoted too exclusively

to the formulae of certain schools or leaders.

In dynamic growth therapy there is a search for causes for the

forces, urges, or needs, that push, drive or motivate individuals. One

seeks to discover the dynamics of the neurosis or psychosis. This type

of therapy is only partly intellectual, however. It is not a purely passive

process of reflection, intellectual gymnastics and resolutions; it is a

growth experience in which the patient feels and learns. This growth

takes place within a relationship between two human beings, an effective

relationship which is of the greatest importance in therapy. There is

release of repressed, clogging and disrupting emotions, through the

expression, recognition and acceptance of the patient's feelings. It is

recognized that the way he feels is more fundamental than what he

thinks. Therapy is not, therefore, just a process of discovery, recogni-

tion, decision and automatic implementation of new ideas and formulae

for satisfactory living. It is a slow, groping process which, in addition

to intellect involves feeling, and furthermore action trial and error in

the practice of living. Since most growth takes place unconsciously, the

process of therapy takes time. The forces of imagination and identifica-

tion (inspiration) are recognized as more important in many people than

reason and will power. The patient must learn to grow out of his hinder-

ing identifications and work through to a new individuation in order to

achieve a satisfying and constructive personality.

Psychiatric Treatment of Alcoholism

Alcoholism is a tremendous problem from every standpoint, social,

economic, and psychiatric. Oberholzer says there are 100,000 persons

suffering from alcoholism in the United States, and alcoholic psychoses

represent from 10% to 15% of the total admissions to mental hospitals.

In the opinion of Henderson and Gillespie (1941), however, the etio-

logical role of alcoholism in the disorders has been exaggerated; they

regard it as more commonly a symptom than a cause.

n 4 6 PERSONALITY AND THE BEHAVIOR DISORDERS [34

In virtue of the numerous factors considered of etiological impor-

tance in alcoholism, including, for example, such psychological factors

as the release of aggressive and sexual impulses, the escape to infantile

omnipotence, inferiority, immaturity, and such physiological factors as

hypoglycemia and allergy, it is not surprising that therapies have been

diverse and many. For the most part these treatments have been purely

empirical (see comprehensive reviews by Marshall, 1940; Moore, 1941,

and Voegtlin and Lemere, 1941).

Acute alcoholism has usually been treated by physiological and phar-

macological methods. Goldsmith (1930) used spinal drainage to reduce

intracranial pressure. Davidoff and Reifenstein (1937, 1939) have used

benzedrine in 28 patients and results were favorable in 26, or 93%.

In chronic alcoholics, however, they got success with benzedrine in only

10% of their patients. Benzedrine will relieve the craving for alcohol

(Wilbur, 1937) as apparently will atropin, strychnine, and caffeine,

which have long been used for this purpose. In his treatment of 675

alcoholics with reduction of alcohol and coincident use of bromides, or

of tonics with gentian and quinine or with atropin and strychnine, 41%

relapsed, 3% improved, and 55% became permanently abstinent. Lam-

bert (1909, 1912) believed that a belladonna, xantholoxylin, and hyo-

scyamus mixture was almost specific for alcoholism. Emetine was used

by Vivian (1929), who insisted on total abstinence and the complete

cooperation of the patient. McFarland and Barach (1933) point out the

relationship between oxygen want and alcoholic intoxication. Inhala-

tion of oxygen with 7% to 10% CO 2 resulted in permanent improve-

ment. Freeman and Watts (1942) tried prefrontal lobotomy on some

cases with negligible results.

The relation of vitamin deficiency to alcoholism is an important one

which is still in the process of investigation and evaluation. While it is

unquestionably important in the therapy of acute conditions, its value in

chronic addiction remains to be determined. Unquestionably, some of

the mental disturbances formerly thought to be due to the toxic reaction

of alcohol have been due to vitamin B deficiency. Bowman, Goodhart,

and Jolliffe (1939) treated 51 patients with Korsakoff's syndrome with

thiamin and their recovery was seven times as great as those treated

with diet alone.

Metrazol has been used in treatment, but there is no evidence indi-

cating that it has any beneficial effect on subsequent drinking habits.

There has been a great deal of work on the use of insulin. Robinsin

(1940) believed that insulin and carbohydrate administration are essen-

tial curative measures. Rivers (1942) worked out a technique of giving

100 cc. of 50% glucose, 30 units of insulin, and 120 mgms. of thiamin

chloride intravenously with a quart of orange juice to drink. He has

treated over 200 patients and has found the results efficacious especially

in the psychiatric complications of acute alcoholism.

The famed Keely cure is believed to have employed apo-morphine.

Fleming (1935) had 25% cures with its use with 36 patients. Purves-

34] PSYCHIATRIC THERAPY 1147

Stewart used it for the purpose of establishing a conditioned avoidance-

response to alcohol. Voegtlin (1940) has undertaken the most intensive

study and use of the treatment by the conditioned response method. An

attempt is made to establish an aversion to alcohol by the production of

nausea and vomiting with the use of emetic drugs. He uses emetine

instead of apo-morphine because its action is more prolonged. He reports

60% to 70% cures and this exceeds any other figure known in the

literature.

Tabori (1933), Knight (1938), Chassell (quoted by Voegtlin), and

Fleming and Tillotson (1939) discuss alcoholism from the psychoanaly-

tic point of view. They generally report poor results, though Knight's

figures for 1942 from the Menninger Clinic are more encouraging

33% were apparently cured or much improved. His figures and those

of Chassell are the best reported for psychoanalysis. The psychoanalysts

raise the important question, whether teaching the patient to become

abstinent can actually be called a cure.

The success of the various forms of religious therapy, we believe, is

attributable probably to affective therapy or the mobilization of positive

affective relationships. Alcoholics Anonymous have reported striking

results (1939). Voegtlin reports that of 2,000 patients they have seen

in the last six years, about 1,000 are considered permanently cured.

Peabody (1930, 1935) has worked out a practical scheme of psycho-

therapy and reeducation which has helped many alcoholics. He empha-

sizes synthesis as opposed to analysis. Strecker and Chambers have

developed Peabody's methods and brought them more into line with

general psychiatric thinking (1339). For Strecker (1941) alcoholism is

a neurosis of introversion. Alcoholism as a psychoneurotic symptom is

thought of as having the function of screening unsatisfactory external

and internal realities.

Psychiatric Therapy for Children

There are two general approaches to therapeutic work with children,

emanating from divergent basic philosophies. One takes the view that

the child has little share in the creation of his difficulties and thus mini-

mizes his role in their resolution. The other sees him as the chief focus

of the problem with a vital part to play in its solution. Many grada-

tions exist between these two extremes out of which arise a variety of

methods of therapy. There are, however, overlappings and syntheses as

each psychiatrist develops an approach best for his own use and which

he modifies according to the needs of the individual patient.

Therapies in Which the Child's Role Is Minimized. Authorita-

tive Approaches. These approaches depend on alteration of intellectual

content or conscious desires to bring about changes in attitudes and

behavior. The emphasis may lie on direction, suggestion, and advice, or

it may lie on habit training, a process of reeducation by consistent repeti-

1148 PERSONALITY AND THE BEHAVIOR DISORDERS [34

tion of appropriate habits. Thorn (1937) has contributed notably to this

latter method.

Environmental Manipulation aims to fit an environment to the child's

needs. Healy (see 1940) first introduced a comprehensive investigation

of the child and his environment in his study of delinquents (for off-

shoots of this work, see Chapter 25 by Paris). The changes may consist

only in getting a child into a group of children nearer his own age,

changing the school, or sending him to camp ; or it may consist in remov-

ing him entirely from some pernicious environment, and placing him in

an institution or in a foster home selected to fit his problems and needs.

An excellent description of this method is given by Rogers (1939).

Social Interpretation. By this method the child's environment is

altered by interpreting his basic needs and the dynamics of his difficul-

ties to his parents, to his teachers, and to other adults who may have him

in their charge. This is a useful adjunct to any method of child therapy.

Therapies in Which the Child's Role Is Maximized. Release

Therapy depends mainly on abreaction for its therapeutic effect. It has

been used especially by Levy (1937, 1938, 1939, 1940) who considers it

especially suited for children who present a definite symptom picture of

relatively short duration that has been precipitated by such a specific

event as, for example, an operation. Its applicability is limited to chil-

dren under ten years of age whose problems are not related to compli-

cating family difficulties, and Levy emphasizes that in many cases it is

best used in conjunction with other approaches.

Play Therapy, which includes such techniques as children's drawings

(Appel, 1931 ; Despert, 1937; Harms, 1941), play with toys selected to

fit the child's situation (Conn, 1938, 1939; Solomon, 1938, 1940),

puppet shows (Bender and Woltmann, 1936), or real group activities on

a children's ward (Bender, 1937), serves two purposes simultaneously.

These various techniques provide a medium by which the child can reveal

his strivings, his tensions, and his reactions to family influences, and thus

they are methods of personality study. They also afford a situation in

which the child can get catharsis by abreacting his aggressions and his

anxieties in a socially acceptable way.

Relationship Therapy is best described by Allen (1942). In this

approach the relationship of the child to the therapist is given major

emphasis. The parent is interviewed by a case worker, while the child

is spending his hour with the therapist. The time spent at the clinic

is looked upon as a growth experience in which both mother and child

participate. The feelings and attitudes characteristic of the child's pattern

of life are from the first brought into the therapeutic hour, as the child

reacts to the separation from the mother, to the necessity of entering into

a relationship with the therapist, and to accepting the limitations of the

situation, which include a fixed allotment of time. Play materials are

available for the child to use in any way he wishes, though there are

definite limitations imposed when the rights of the therapist are threat-

34] PSYCHIATRIC THERAPY 1149

ened. The content of the play and the accounts of past events and reac-

tions are not interpreted on a historical basis, as in psychoanalysis, but

as a revelation of present feelings, both negative and positive. The value

of the therapy lies in the child's own experiencing of his feelings and

impulses with someone who is willing to start with him as he is at the

moment, and who will help him to bring all the turmoil of his changing

feelings into the therapeutic hour. Essentially nonintellectual, its thera-

peutic influence rests on an experience of relationship to the therapist

through which the child can gain a realization of himself as an individ-

ual in his own right, capable of participating in his own changes. With

this realization, growth can be resumed with lessened anxiety and denial.

Psychoanalysis. In the psychoanalysis of children, the intensity and

duration of treatment is greater than in other child therapies. The

patient may be seen every day for a period of from one to three years.

Though the aim of child psychoanalysis is always to get at the uncon-

scious underlying causes, and subsequently to resolve them, there are

various approaches. These differ in both method and breadth of appli-

cability. Three such variations are herewith presented.

Anna Freud (1928), who feels that psychoanalysis should be adopted

only for those children suffering from a real infantile neurosis, believes

that no true transference neurosis develops, as in the case of adults,

because of the present existence of real and natural parents in the child's

life. A negative attitude toward the analyst must be replaced by a posi-

tive attachment, however, before the child's unconscious can be reached.

There is, therefore, a period of preparation in which such a connection is

consciously fostered by the analyst's allying herself with her young

patient, showing herself as a trustworthy, useful, or powerful adult.

Play techniques are valuable chiefly in revealing the child's various reac-

tions, attitudes, and aggressions, but they are not considered to be deeply

symbolic. She regards free association as more significant. Dreams, day-

dreams, and drawings she finds much more profitable for direct inter-

pretation. The analyst has also an educational role because the child's

weak super-ego needs reinforcement in regulating the instinctual life.

Toward the end of analysis, consequently, there is a pedagogical period

to assist the child in adjusting to his outside world.

Melanie Klein (1937) feels that analysis is valuable in the treatment

of every disturbance and even in assisting the development of the normal

child. She believes that a true transference neurosis is produced. Play

activities are considered to be on a par with adult speech and thus may

be used in the same way as free association. She immediately interprets

unconscious material in order rapidly to reduce anxiety and the uncon-

scious sense of guilt. Klein thinks that the analyst should refrain from

exerting any kind of educational influence.

Aichorn (1939) uses psychoanalytic principles in the treatment of

delinquents, but his procedure is notable for its flexibility. A positive

relationship is deliberately fostered and he achieves this quickly in a

H 5 o PERSONALITY AND THE BEHAVIOR DISORDERS [34

variety of ways. He may allow a child to carry out his aggressions with-

out restraint until the child develops fear and feelings of guilt which

make him ready to accept help from the therapist. The child is then

treated on the basis of the transference. Aichorn's approach is essentially

reeducation on psychoanalytic principles.

Some Statistics of Psychiatric Therapy

In view of the magnitude of the problem involved in the control of

nervous and mental disease, it would be highly desirable to know which

of the methods of treating each of the various reaction types is most

effective. It is easier to state the importance of the problem statistically,

however, than it is to measure the efficiency of the various therapies

statistically. In the general hospitals of the United States there are only

375,000 beds, whereas in the mental hospitals there are 430,000 beds.

There are nearly 400,000 patients in these mental hospitals, and approxi-

mately 100,000 new patients admitted annually (for a survey of these

statistics in European countries as well as America, see Landis and Page,

1938). The investment in mental hospitals alone represents one billion

dollars. But the problem is even broader. General medical consultants

in large cities find that from 45% to 50% of their consultations concern

functional conditions wherein no organic pathology can be found. More-

over, psychiatric or emotional factors are estimated to cause from 50%

to 65% of physical illnesses. Yet few of the 5,000 general hospitals have

provided for psychiatric examinations and care of the 8,000,000 cases

they admit annually. If the time each patient stayed in a hospital could

be reduced by several days by attention to the emotional factors in physi-

cal illness, the public could be saved millions of dollars annually.

Furthermore, in view of the problems that will arise from the Second

World War, certain statistical facts from the army records of the First

World War are important. Between April, 1917 and December, 1919,

there were 97,657 members of the armed forces admitted for neuro-

psychiatric conditions. Over 8,000 men were returned from overseas

prior to June, 1919 for neuropsychiatric illness. These psychiatric dis-

orders developed despite the fact that local draft boards rejected 549,099

on neuropsychiatric grounds. When it is estimated that every man who

"breaks down" during military service will cost the government about

$30,000 during his lifetime, the importance of extreme vigilance by the

examining physicians on draft boards is clearly indicated ( for a discus-

sion of the unit in military service, see Chapter 27 by Stearns).

In connection with the general impression that the results of psychi-

atric therapy are disappointing, Strecker and Ebaugh (1940) point out

that, "It is conservatively estimated that between 60 and 75 per cent of

the psychoses which are comparable to what the internist would desig-

nate 'acute' are recoverable. Particularly in psychiatry do we meet con-

ditions and situations which are capable of considerable modification in

a favorable direction even though a complete cure may not be effected.

34] PSYCHIATRIC THERAPY n 5I

This is particularly true in incipient and early schizophrenia, and the

failure to recognize this potentiality has made the outlook seem even

gloomier than it really is/*

In recent years, an increasing number of articles reporting the pro-

portions of cures, social remissions, improvements, and unrecoverable

patients for various therapies have appeared. A few summaries of these

follow. Inevitably these statistics are open to misinterpretations. The

standards for recovery are variable for different investigators, and it is

difficult to draw lines between the various degrees of recovery. There

is great need for statistical data from studies that make long-term follow-

ups of the patients treated by each of the major forms of therapy.

Bond (1921, 1923, 1941) has long been interested in the problem of

prognosis, and he has published results from various types of therapy at

the Pennsylvania Hospital over a number of years. In 1937, Bond and

Braceland reported on a five-year follow-up of 626 unselected cases of

psychosis. This paper is especially interesting because it furnishes a

baseline from which the results from the newer therapies can be judged.

In Table I, we quote their master table for this purpose.

TABLE I

PROGNOSIS IN MENTAL DISEASE BEFORE NEWER THERAPIES BASED ON OUTCOME

AFTER FIVE YEARS

Dementia Praecox

No.

Cases

, 116

No. Re-

covered %

12 10.0

No. Im- N

proved %

25 21 5

o. Unim-

proved %

66 56 8

No.

Dead

10

No.

Lost

3

Manic-Depressive .

, 171

86 50 2

19 11 1

30

24

12

Paresis

38

13

8

5

12

Involutional Melancholia . .

47

60

12 25.5

22

10 21.2

8

10

3

13

23

2

4

Senile

50

2

4

8

31

5

Alcoholic

10

1

3

2

4

37

21 56.7

7 16.9

4 10 8

3

2

Paranoid Conditions

9

72

3

27

3

13

2

11

8

13

Psychopathic

8

4

2

1

1

Encephalitics, Adult

8

1

1

2

2

2

Total

626

200

102

146

129

48

35%

18%

25.5%

22%

(From Bond and Braceland, 1937)

Varying proportions of favorable results have been reported for

insulin-shock therapy in schizophrenia. Sakel (1938) got his best results

in cases where the symptoms had recently appeared. In a series of ap-

proximately 50 such cases, "70% showed full remission (apparently

cured) and another 18% showed social remissions following treatment.

... In other words, 88% of our recent cases showed positive results

after treatment" (p. 133). These figures are higher, however, than those

reported by later investigators (see review by Shipley and Kant, 1940).

When the results obtained in 495 schizophrenics treated in 22 Swiss

hospitals were analyzed and classified according to duration of psychosis

before treatment (Miiller, 1938), the proportions of full or social remis-

ii 5 2 PERSONALITY AND THE BEHAVIOR DISORDERS [34

sions were : for up to six months, 59% ; for from six months to one year,

$2%; for from one year to two years, 27%; over two years, 11%.

Malzberg (1938) has compared outcome in 1,039 insulin-treated schizo-

phrenics with outcome in 1,039 controls matched with the treated cases

for institution, age, sex, and type of schizophrenia. The results showed

13% recovery and an additional 54% improvement in the treated cases,

as compared with 3.5% recovery and 19% improvement in the control

group. A breakdown according to duration of symptoms revealed the

following proportions of recovery. Treated group: up to one month,

43% ; one to six months, 33% ; seven to twelve months, 16% ; one to

two years, 12% ; and three to five years, 4%. Control group: up to one

month, 8% ; one to six months, 7% ; seven to twelve months, 0% ; one

to two years, .6% ; and three to five years, 0%. Not all recoveries are

permanent, however. Muller (1938) reported relapses in from 6% to

13%, Malzberg (1938) in 24.5%, and Bond (1941) in 18%. In spite

of these relapses, it is generally agreed that the response to insulin-shock

is so favorable and so immediate that it represents a promising therapy

for schizophrenia.

Striking results have also been reported for metrazol therapy in

schizophrenia (Meduna, 1935). When Meduna and Friedman (1939)

analyzed the combined results from 2,937 cases treated in European and

American hospitals, the gross European results were 30.37% full remis-

sion, and the gross American results were 19.86% full remissions and

38.43% improvement. When these results were analyzed according to

duration of symptoms before treatment, they revealed : for less than six

months, 60.95% complete remission and 20% improvement; for six

months to one year, 36.82% full remission and 23.13% improvement;

for over one year, 8.36% full remission and 37.76% improvement.

Mortality was .29% for the 2,937 cases. In spite of these statistics, it is

generally agreed that metrazol therapy does not compare favorably with

insulin therapy in schizophrenia (see review by Shipley and Kant, 1940).

Metrazol was soon used in other disorders, however, and it has shown

particularly good results in the affective psychoses. Not only has the

proportion of recovery from affective psychosis been high (82% in

the cases treated by Low, et al., 1938) but it remains high regardless of

the duration of the symptoms, and the duration of attacks was shortened

from an average of one year in 8,000 untreated cases to an average of

7.5 weeks in those who received treatment. Results of metrazol therapy

in severe cases of neurosis have been reported by Shapiro and Freeman

(1939). Recovery occurred in five of seven of their cases of obsessive-

compulsive neurosis, in three of six cases of anxiety neurosis, in two of

seven cases of reactive depression with improvement in three others, and

recovery in four of five cases of conversion hysteria.

The electro-shock treatment, introduced by Cerletti and Bini (1938),

has developed so many advantages over metrazol that it has now almost

replaced the latter. The results of electro-shock in 108 cases treated at

the Pennsylvania Hospital appear in Table II. Like metrazol, this form

of shock therapy is most effective (over 80% remissions) in the affective

34] PSYCHIATRIC THERAPY 1153

disorders. It is quite ineffective in schizophrenia, and it is of question-

able value in the psychoneuroses.

TABLE II

RESULTS OF ELECTRO-SHOCK THERAPY IN 108 CASES TREATED

AT THE PENNSYLVANIA HOSPITAL

Diagnosis

Involutional Melancholia ,

Re-

covered

%

... 85

Im-

proved

%

15

Unim-

proved

%

Relapsed

%

5

Total

Treated

20

Manic-Depressive, Manic ,

... 70

30

10

Manic -Depressive, Depressed . ,

Schizophrenia

... 72

10

7

18

93

o

49

16

Undiagnosed Psychoses

, . . 37.5

62.5

12.5

8

Psychoneuroses

. .. 60

40

o

5

Freeman and Watts (1942) have carried further Moniz's work on

prefrontal leucotomy or lobotomy. The statistical side of the therapeutic

aspect of their results with 80 patients appears in Table III.

TABLE III

RESULTS OF PREFRONTAL LOBOTOMY PRESENT STATUS OF PATIENTS

WITH PREFRONTAL LOBOTOMY

Regu-

Studying

larly

or

Em-

Partially

House-

At

Insti-

Disease

No.

ployed

Employed

keeping

Home

tution

Dead

Involutional Depression . . .

.. 38

4

3

12

11

4

4

Obsess. Tension States

. . 18

7

7

2

2

Schizophrenias

. . 12

3

3

1

3

1

1

Psychoneuroses

8

4

1

1

1

1

Undifferentiated

4

2

1

1

Total 80 20 7 22 18

(From Freeman & Watts, 1942)

When the female sex hormones became available for therapeutic use,

it was natural that they should be tried as replacement therapy in mental

conditions associated with the menopause and involutional period when

the production of these substances by the body is diminished or stopped.

Werner, et al. (1936) compared the progress of eight control patients

with involutional melancholia and nine others whom he gave 1 cc. of

theelin daily for 20 weeks, and reported enthusiastically that five patients

in the treated group improved markedly, while only one in the control

group improved. Schube, et al. (1937) and Bowman and Bender

(1932) failed, however, to get beneficial results from estrogine admin-

istration in this psychosis. In fourteen cases of true melancholia, Roter-

nich (1941) found that endocrine therapy failed to produce results

appreciably better than those which occur spontaneously. When Palmer

H54 PERSONALITY AND THE BEHAVIOR DISORDERS [34

(1941) treated eleven patients with stilbestrol, eight showed no change

during three months, and three became increasingly agitated and de-

pressed. He concluded, therefore, that estrogenic therapy had no favor-

able effect on the involutional psychoses in the female. On the other

hand, when Burlingame (1941) treated 63 cases of involutional psy-

chosis with estradiol benzoate and estrone, 9.5% recovered, 22.2%

improved considerably, and 27% were improved. Thus, a total of 57%

or 58% were "apparently benefited. " Our own experience with estro-

genic therapy has been disappointing. Not infrequently the agitation has

been increased, and disturbing pelvic sensations have at times further

complicated the psychological problems.

Several outstanding summaries of prognosis in the psychoneuroses

have been made. Riggs (1923), reporting on the condition of 800 cases

treated at Stockbridge following their discharge by an average of two

years, gave the following figures: no improvement in 1.9% ; improve-

ment in 15.7% ; much improvement in 49.2% ; and complete recovery in

33.1%. In 1940, Coon and Raymond made an extensive follow-up of

1,060 cases treated at Stockbridge, and they gave the following sum-

mary : no improvement in 6.4% ; improvement in 27.6% ; much improve-

ment in 29.9% ; and no statement about 36.0%. Out of 1,186 patients

treated at the Cassel Hospital, at from one to thirteen years after dis-

charge, Ross (1936) found 31.1% well, 7.2% had improved, and 61.7%

were lost sight of. Hinsie's (1935) study of 61 psychoneurotic patients

treated at the New York Psychiatric Institute showed 13% recovered,

55.7% improved, and 31.2% unimproved.

By far the most searching and comprehensive surveys of the results

of psychoanalytic therapy are those of Knight (1938, 1941). He pre-

sents tables using the combined categories and criteria from the Berlin

Psychoanalytic Institute, from Hyman and Kessel, from the London

Psychoanalytic Clinic, from the Chicago Psychoanalytic Institute, and

from the Menninger Clinic. We present herewith only a composite of

these tables from Knight (1941).

TABLE IV

KNIGHT'S (1941) COMPOSITE TABLE ON PSYCHOANALYTIC THERAPY

_ __

6 Mos. Change

No. Broken or Appar. Much

Cases

Psychoneuroses 534

Sexual Disorders

Character Disorders . . .

Organ Neuroses and Or-

ganic Conditions ....

Epilepsies 10

Migraine 1

Stammering 15

Chronic Alcoholism .... 28

Psychoses 151

Totals "952~ 292 660 183 186 55.9% 201 90 44.1%

Cases

Off

Longer

Cured Improv.

AC. MI

Improv. Worse

I.NC

534

151

383

125

117

63.2

110

31

36.8

47

14

33

12

4

48.5

18

4

51.5

111

28

83

13

3^

56.6

25

11

43.4

55

23

32

15

10

78.1

6

1

21.9

10

5

5

1

1

3

1

1

1

15

3

12

3

3

3

3

28

9

19

3

4

7

5

151

59

92

10

13

25.0

37

32

75.0

34] PSYCHIATRIC THERAPY 1155

A review of therapeutic statistics in psychiatry shows that the rate of

melioration in the psychoneuroses at the time of discharge is higher

(ranging from 60% to 80%) than in the psychoses (40%). On the

other hand, the rates (41% to 54% continuing improved) for the psy-

choses in the follow-up reports for five-year periods by Bond (1921a,

1921b, 1925, and Bond and Braceland, 1937) compare favorably with

follow-up rates for the psychoneuroses in Ross's (1936) reports from

England (38%) and in those by the Riggs Foundation (47.2%). These

figures appear to indicate that the rate of improvement among psycho-

neurotics who come to psychiatric institutions for treatment (and a great

many remain in the community untreated, or are treated by private prac-

titioners) is not far removed from the rates of improvement in the psy-

choses. Moreover, hospital reports show better results for the treatment

of the psychoses than for the treatment of the psychoneuroses. The sta-

tistical results of psychoanalytic treatment (see Table IV) of the psycho-

neuroses differ little from those of other methods of therapy. It is

possible, however, that psychoanalysis has treated more severe cases on

the whole than have the other methods.

The therapeutic statistics of psychiatry appear to justify only the

conclusion that the essential factors in cures are still unknown. Never-

theless, one gains the impression that therapy does something and is

effective. One gains the impression that certain types of therapy are more

effective in particular types of patients than in others. However, the

statistics appear to indicate that any therapy is in itself more funda-

mental than the type employed. There is something basically effective

in the process of therapy in general which is independent of the meth-

ods employed.

Conclusion

The following table shows the various methods of treatment that are

available to the psychiatrist. A great deal of the success in treating a

patient will depend on the psychiatrist's selection of the method or meth-

ods of treatment appropriate to the individual patient. Psychiatric ther-

apy must be highly individualized. Every patient is an individual with

his own particular and often fortuitous experiences, temperament, and

goals. Mass methods, routinized procedures, and favorite (popular) gen-

eralized formulae are bound to fail in many instances.

In addition to the kinds of treatment available, something else must

be considered, namely, which of the various levels of therapy is appropri-

ate for the individual patient. At the level of critical illness, medicines,

drugs, narcosis, and authoritarian therapy are the only methods an expe-

rienced doctor would consider. At the level of vegetative convalescence,

nursing, support, and reassurance are the methods to use. Next is the

level wherein routine, schedule, occupational therapy, and socialization

are useful. Then there is a level where personality study, abreaction, and

the description of mechanisms are useful methods. There is then the

1156 PERSONALITY AND THE BEHAVIOR DISORDERS [34

TABLE V

METHODS OF THERAPY IN PSYCHIATRY

ENVIRONMENTAL (manipulation, change,

travel, diversion)

(physiotherapy, exercise,

PHYSICAL

games)

MEDICAL (drugs)

PSYCHOLOGICAL

Human Relationships

Support, Encouragement, Reassur-

ance

Directive Authoritative

Suggestion

Hypnosis

Direction Authoritative Guidance

Routine Schedule

Work Occupational Therapy

Play Art Literature

Rest Exercise

Intellectual Explanatory

Re-education

Principles of Mental Hygiene

Study

Work Play Rest Socialization

Personality Study

Explanation of Mental Mechanisms

Emotional Release

Emotional Expression Release, Ab-

reaction

Analytical (intellectual, abreactive, re-

lationship)

Analytic Psychology

Psychoanalysis

PSYCHOLOGICAL (Continued)

Analytic, Educational

Dynamic Growth Therapy Treat-

ment as growth through experi-

ence, learning, and education

Relationship therapeutic (support,

encouragement, acceptance, in-

dividuation)

Abreaction to make possible emo-

tional stability, eliminate disso-

ciation, establish reassociation,

and more stable integration,

open the way for clarification

and insight. (Emotion)

Understanding, development of

(unconscious conscious). (In-

tellect)

Practice Action (development of

capacities and skills, and habits

of courage, persistence, endur-

ance, and reliability)

Inspiration (identification with

ways of approaching problems

by therapist through kinds of

questions he asks, identification

with friends and heroes in his-

tory, literature, or life ; social

ideals; interest; enthusiasm)

Self-Direction (development of

independence, release, and free-

dom from ineffective bonds or

fixations from the past). (Will)

Growth in Self-Realization (find

satisfaction in use of abilities

for needs of others cooperation

to attain self-respect and so-

cial respect). (Socialization)

level of seeing relationships, i.e., the level for deep therapy or psycho-

analysis, which leads into the realm of primitive, archaic impulses and

phantasies. And finally, comes always the level where the patient must

reach out and test his hypotheses and perspectives ; where he must try

to live a new life and practice creative living. The psychiatrist must

decide, from a multitude of minor cues obtained in the clinical examina-

tion, at which level he can best approach each of his various patients,

and when he should change his method.

A great deal of difference exists among psychiatrists in the ability to

understand, and hence to help, patients. This capacity does not depend

upon intellectual ability or on ability to classify diseases. There is much

34] PSYCHIATRIC THERAPY 1157

variation in rapport between doctor and patient which does not depend

entirely upon the patient's transference. The doctor must make a con-

tribution here upon which the success or the failure of treatment often

depends, and the capacity for this varies widely. It may be the difference

between knowledge and art, the difference between medicine as a science

and medicine as an art of practice.

No therapy, however helpful and useful in itself, will be of value

unless a constructive relationship is developed between patient and doc-

tor. The therapist is not entirely responsible for the way this develops.

He is not responsible for the form of the transference, for instance, but

he must be aware of the various possibilities and be able, through under-

standing and through a sympathetic reception of the patient's expres-

sions, to help him make constructive steps in his growth. The therapist

must preserve a careful balance, however, between showing sympathetic

understanding of the patient's point of view and feelings, and either

agreeing with him or antagonizing him. He must also refrain from

aloofness and from irritating superiority or knowingness, even while he

remains intellectually objective and empirical in his approach. The ther-

apist must not make decisions for the patient unless it is absolutely neces-

sary, but he can frequently encourage constructive thinking by asking

tactful and stimulating questions. He should enable the patient to feel

that he, the therapist, has real interest in him and his problems.

Psychotherapy cannot rely on the myth of the omnipotence of the

rational. In therapy as in life, the irrationals are met, and they cannot

be eradicated by appeals to reason. They must be resolved by patient use

of free association or semi-free association, by release through abreaction,

and by the insight and the new perspectives that come through a clarifi-

cation of the transference and from a breakdown of resistance.

Psychotherapy is not just talking to patients. It is not humoring

them. Neither is it the giving of platitudinous suggestions. Nor is it

merely the prescription of sedatives and placebos. It is more than remov-

ing an irritating, stubborn, and temperamental person from the home to

give a family relief. Psychotherapy has well-defined goals. It has well-

defined rules and methods (proven for the most part) of reaching these

goals. New ideas, attitudes, correlations, and perspectives must be woven

in the web of a patient's life according to the laws of emotional health,

and it is a successful affective relationship with the therapist that helps

most constructively to cultivate in a patient these dynamisms of effective

living.

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(Preface by J. B. S. Haldane.) New York: Coward-McCann.

WOLF, A. W. M. 1941. The parents' manual. New York: Simon & Schuster.

WRIGHT, H. 1931. The sex factor in marriage. New York: Vanguard.

WRIGHT, M. 1935. Getting along with people. New York: Whittlesey House.

Chapter 35

THE PREVENTION OF PERSONALITY DISORDERS

By GEORGE S. STEVENSON, M.D.

THE MOST INSPIRING GOAL of our search for more knowledge of the

causes and determinants of personality and of the disorders of behavior

is the possibility of applying this knowledge to the refinement of human

living and to the prevention of disorders of behavior, in other words to

add to mental hygiene. Mental hygiene is not a hygiene through a "men-

tal approach" as Williams (1932) implied in his Is There a Mental

Hygiene? but a prevention of mental disorder on any basis. It has been

shown (Chapters 16 to 24) that these disorders are the outgrowth of a

multiplicity of factors, some more important than others, some indis-

pensable in the production of certain forms of disorder. In other words,

some burdens on the efficient behavior of the individual are general and

some are quite specific. It has been shown in this book that this com-

plexity of causative factors is very great and that the combinations are

various both as to the types of factors and their sequence. The impor-

tance of the same factor may change greatly from case to case. There-

fore, persons with apparently similar disorders are apt to have been

influenced by very different combinations of factors. Each person is an

"experiment of nature" in that nature has put each together in a new

way; no one is exactly duplicated.

In most instances there are several factors that can be considered

important in precipitating a certain disorder of personality or behavior,

any one of which might be credited as being the last straw in breaking

"the earners back" depending on when it happened. The weight of the

combination is important. In some instances, therefore, one is faced with

several alternate avenues of attack in the effort to spare or unburden

"the camel." Thus the preventive effort is not only individual in terms

of the person to be helped, who has his own combination of causes, but

is likewise individual for the person offering the help, who has his own

technical strengths and opportunities for using this or that approach.

In some instances the overburdening is slight, and in such cases a

change in any one of many factors may suffice to lighten the load enough

to remove a threat. In that case, there is wide choice in the factors to be

attacked or hygienic methods to be used. By the same token, a measure

undertaken to affect a community-wide factor, or one existing otherwise

on a large scale, will affect many people favorably, but leave some of the

1164

35] PREVENTION OF PERSONALITY DISORDERS 1165

more seriously disordered still overburdened. In other cases the burden-

ing may be so heavy as to demand a change of every possible factor.

Then there is little choice. This possibility of alternate choices is not

always fully appreciated, with the result that one way is often considered

right and all others wrong. This results in unnecessary confusion. 1

Various Concepts of Prevention

In addition to differences in the choice of methods of prevention there

are categorical differences in the very meaning of prevention. These dif-

ferences cause no trouble if they are understood. They result in fruitless

argument if they are not. It seems important, therefore, to sort out, label

and illuminate these different categories of prevention in order that effort

that is quite appropriate in striving for one may not be wasted on

another.

Probably the most frequent preventive effort could be classified as

"presumptive prevention." This effort is based on the knowledge that

certain conditions (familial, physical, psychological, and social) antedate

and appear to be etiologically related to behavior disturbances. The

shut-in personality is said to precede dementia praecox. It is conse-

quently thought to be appropriate to correct or prevent this condition in

the hope of forestalling dementia praecox. It is presumed that the ante-

cedent condition is causative or an essential intermediate step in the

development of the disorder and that its correction will be preventive.

If this presumption is merely slipshod "science" to avoid the trouble of

further research, it is a retardant to more certain and effective preven-

tion. If, on the other hand, it is recognized for its limitations, accepted as

tentative, and accompanied by vigorous efforts to prove or disprove the

presumption, it is an important step in scientific progress. If it is a way

of doing the best possible, until science shows its falsity or shows a bet-

ter way, it maintains activity in the field, enriches experience and gives

the weight of logic to what is done for people for whom something will

be done anyway. Presumptive prevention is well illustrated by the fol-

lowing excerpt from an article on prevention by H. L. Levin :

Where the parents or others have been capable observers and are

sufficiently cooperative to tell all they know, a history of these faulty

habitual reactions in childhood can be obtained in a large proportion

of the cases of adolescent or adult praecoxes who are committed to a

state hospital. Four such cases are described below from the records

of a state hospital, illustrating Meyer's conception that the psychotic

symptoms necessitating commitment to state hospitals are but nat-

1 This is in itself a behavior and personality disorder known as the "incapacity

to accept difference." It is the emotional need that "my way" be the "right way"

and all others "wrong ways" and results in a tendency to force others to agree with

me, take my advice and follow my example. Emotional maturation has been inter-

preted as in part a progressive capacity to accept differences. This problem would

then evidence emotional immaturity, a need for a world revolving about the self

as it did in childhood.

n66 PERSONALITY AND THE BEHAVIOR DISORDERS [35

ural outgrowths of faulty reaction habits of childhood. These are

followed by the case records of our children treated at child guidance

clinics for abnormalities in mood and conduct strikingly similar to

those of the committed adults and treated with apparent success for

two to four year periods.

Although the four problem children seemed to have been definitely

started on the praecox route, psychiatric intervention appeared to

have vitiated some of the malignant elements in the environment and

brought about for a period now of from two to four years, an appar-

ent arrest of the praecox process. The question is raised whether

similar intervention during the childhood of the four adult praecox

cases might not have been the means of preventing chronic, if not

lifelong, psychoses. (1933, p. 806)

It is chiefly important that "presumptive prevention" be recognized

for what it is. If, for example, the shut-in child is to be dealt with on

the one hand by the chance buffets of parents, teachers or companions

or else on the other by a designed attempt to bring him into close, more

comfortable, touch with others, it is better to follow the latter course

even though it is a presumptive prevention, for at worst it is likely to

be no worse than the former, and in any case our knowledge of such

children is enriched by the attention to the problem. It would, however,

be a mistake to believe that thereby the last word in a preventive pro-

gram has been said.

According to another concept of prevention, it is considered that a

disorder may be forestalled by treating a definite but simpler or earlier

disorder. This might be called "therapeutic prevention." It is only rela-

tively preventive in that a problem has already arisen. It depends for its

rationale upon the fact that most disorders of personality and behavior

are progressive. They seldom burst forth on short notice in full form,

although there are clear-cut instances of this, but rather they are cumu-

lative, one step in a series leading to another. By treating one step the

next is prevented. Thus the prevention of the most serious disorders

the psychoses leads one to give serious therapeutic attention to alco-

holism, neuroses, psychosomatic disorders, antisocial behavior and dis-

torted personality, the lazy, the moody and the overscrupulous. The

distinction from presumptive prevention is not always clear. Sometimes

both presumptive and therapeutic prevention are involved.

This form of "relative prevention" is clearly justified, but again it

must be recognized as only "half a loaf" and should be seen as an incen-

tive to discover the way to the other half. The treatment of school fail-

ure might be considered a therapeutic preventive of truancy and delin-

quency and might involve a study of the causes of the failure and an

adjustment of the school program so as to bring the child again into his

social or age group. This approach to the problem leads to the discovery

and correction of the other half of the problem that would be missed if

the school failure were cured merely by removing the child from school

and putting him to work. (See radical prevention.) Kasanin and Veo

35] PREVENTION OF PERSONALITY DISORDERS 1167

(1932) found two groups of serious mental cases who could be recog-

nized in advance as problems by their teachers : the odd, queer, peculiar ;

and the shy, backward, and passive. These offer possibility of preven-

tion and they constitute half of the prospective cases of dementia prae-

cox. The other prospective cases seem to offer no warning to the teacher

of the impending disaster. This forewarned half, however, points to the

need to give to the prospective teacher some new information and expe-

rience to be included in his training, and they also tell the community

to enrich its resources for dealing with these problems.

Witrner, in a careful study of the objective of prevention as a purpose

of child guidance clinics, questions seriously whether there is good

foundation for such an expectation. She says :

A plan for preventing psychoses through the treatment of chil-

dren who arc likely to develop vSerious mental disorders falls down,

then, for various reasons. In the first place, psychiatrists disagree

as to the causes of the functional psychoses. The psychoanalytic

and other dynamic theories, emphasizing as they do psychogenetic

factors, offer greater hope than the others for prophylactic work in

this area, but they give little support to the belief that the relative

strengths and weaknesses of a child's personality can be so assessed

that the likelihood of his developing a psychosis can be estimated.

Then, on the factual side, there is little to substantiate the belief

that the findings with respect to prepsychotic personality traits are

reversible. On the one hand, there arc large numbers of psychotic

patients who as children appeared, according to all reports, to have

been normal. On the other, even if it is granted that children with

certain personality traits are more likely than others to develop men-

tal disorders, there is nothing to indicate how much greater that

likelihood is, nor does the little evidence available suggest that it is

excessive. Accordingly, a mental hygiene program aimed at iden-

tifying the potential psychotics among school children would locate

only a certain proportion of them at best and would expend much

effort upon a group whose chance of mental disease is slight. (1940,

pp. 283-284)

Similarly the clinical approach to delinquency is handicapped by the

fact that in so far as delinquency is a clinical problem it is a problem of

dealing with a disturbed personality, whereas delinquency is a legal label

of certain symptoms that have offended society. Unlike the prevention

of mental disease, however, there are other paths to the prevention of

delinquency that are open beyond the clinical sphere. Meyer clarifies the

preventive situation as follows:

The habits clinics were developed, and since then The National

Committee for Mental Hygiene has been enabled to establish its child-

guidance clinics, nominally for the prevention of delinquency, but

really as a step toward reaching the broader needs of health, happi-

ness, efficiency, and social adaptation.

We are at times made to believe that all our mental hygiene

work and effort aims largely at the prevention of "insanity and

n68 PERSONALITY AND THE BEHAVIOR DISORDERS [35

crime," just as the early advocates of psychopathic hospitals made it

look as if, through the creation of a psychopathic hospital in each

state, the existing state hospital care would then be made less expen-

sive and perhaps in part unnecessary. To be sure, early work means

a heading off of some of the disastrous depth of aberration and

deviation and much unnecessary blundering. But the chief goal is

much more direct; it offers prompter and more and more enlightened

help both to patient and family and to the community in respect to

really new problems, largely left to themselves before; it is a direct

service to the positive needs and opportunities of the community in

behalf of what I reemphasize as health, happiness, efficiency, and

social adaptation. (1925, p. 675)

Somewhat related to therapeutic prevention is another form of rela-

tive prevention in which a problem is prevented by substituting a less

serious problem in its place. This is dependent upon the fact that at

certain possibly all stages in the development of problems there are

several alternate lines of development, and that with outside help the

progression can be turned into the less serious channel. Voluntary tics

are especially subject to this "substitutive-prevention." A beginning

tendency to nail biting may be turned into pencil-biting or some other

socially less objectionable, therefore individually less burdensome, behav-

ior disorder, and thus bring the disturbance to a lower level. In fact

such substitutions take place spontaneously again and again in the course

of the development of a behavior pattern. Bios has shown these shifts

by detailed longitudinal case studies and also how the child reverts to

older patterns when the new is unsuccessful. Again in this approach it

must be kept evident that the foundation of the problem remains un-

changed; the effort is palliative; and if nothing is done to improve the

basic condition the achievement is apt to be temporary. It gives respite,

however, for more fundamental help and is valuable where no better

opportunity for prevention is offered.

A third form of relative prevention consists of circumventing a dis-

order by modification of general conditions that have nothing specifically

to do with the determination of the problem but merely permit its occur-

rence. The specific conditions are unmodified. This measure of pre-

vention may involve the change of home or the imposition of segregation

and constraint. It is analogous to the prevention of cancer by removal

of tissues in which cancer might occur. It is "radical prevention." Since

many hazards are environmental and are a threat to many persons a

modification of one person affords no protection to others. Most of our

penology operates this way. Such a process has its place particularly

in acute emergencies but is seldom final. It contributes little to our

knowledge. It is hazardous if there is no attempt to modify these threats

in the interim, but allows the return of the person or the exposing of

others to the same deleterious factors.

The fact that these three forms of relative prevention therapeutic,

substitutive, and radical are presented as a separate category does not

35] PREVENTION OF PERSONALITY DISORDERS 1169

mean that in actual practice they can be so isolated. In fact they are

seldom applied in pure form, but exist in combination with each other

and with presumptive and other types of prevention. In implication,

however, they are somewhat different and for this reason warrant clear

analysis in order that the implications of one may not be applied to the

other.

The acme of prevention is of course the removal of causes or the

application of scientifically validated preventive measures. This "abso-

lute prevention' 1 is harder to achieve in multidetermined behavior dis-

orders than in the case of specific medical problems, and so there is a

marked lag between treatment and prevention. It is, however, quite

practical in the case of syphilitic and toxic behavior disorders. This

"rational prevention" should not, however, be permitted to cloud the

value of "empirical prevention" of which ordinary vaccination is a good

example. While empirical measures may not afford the satisfaction of

a good rationale, they are scientifically validated and clinically effective.

In the interests of science they should be explained, but they are not

presumptive. It is an established fact variously explained that religious

experience, especially of the Salvation Army form, has in many persons

markedly altered the course of alcoholism and some other disorders.

This is a fact to be studied and understood, not one to be ignored because

it is not understood.

For purposes of avoiding confusion, then, it is well to differentiate

the various forms of prevention and to associate with each its values and

limitations. These forms are :

Presumptive Prevention based on the alteration of earlier or asso-

ciated conditions presumed to be of causative importance.

Relative Prevention :

Therapeutic based on the treatment of earlier less serious stages

of a disorder in order to prevent more serious stages.

Substitutive based on the substitution of a less for a more seri-

ous and progressive disorder.

Radical based on the changing general conditions of living so as

to evade factors of disorder.

Absolute Prevention :

Rational based on the elimination of proved causes.

Empirical based on the application of unexplained measures of

proved value.

Focusing Prevention

Preventive programs, however conceived, must be pointed up strate-

gically or else find themselves dissipated or misplaced. This effective

focusing of prevention demands that it be directed at human functions

that have to do with behavior disorders. Thus prevention becomes

eugenical, physiological, psychological, and environmental. It needs also

H 7 o PERSONALITY AND THE BEHAVIOR DISORDERS [35

to respect certain general principles or facts about human behavior.

Eight such principles will be considered.

Probably the most important is the fact that human behavior is multi-

determined. Entering into behavior are multitudinous factors of the past

experience and current state of the four levels of human functioning

listed above. As expressed by A. T. Mathers (1931, p. 486), "the

causes are multiform and variable, vague and subtle, rooted widely and

deeply in the very fundamentals of life and society/' This means that on

the one hand prevention may need to be complex, and on the other hand

that many different professional groups have legitimate opportunity or

obligation to participate. It means that the royal road to prevention is

traversed by these professions working in unison but that lesser roads

are open to them individually in connection with their daily jobs. Thus

the doctor, the lawyer, minister, employer, nurse, social worker, teacher,

public health functionary, all meet with opportunities as a part of their

daily jobs to influence the personality and behavior of those whom they

serve or those whom their clients may in turn influence. They have

opportunity to influence them eugenically, physically, mentally, and

through improvement in their social settings. If one studies the history

of any service agency, he finds that though it started with one profes-

sion it comes to add others to its force ; the schools add doctors, nurses,

and social workers, and the hospitals add teachers and social workers

in the effort to meet this principle as their cases reveal it. Now the

coordinating council and several other patterns of community efforts in

behalf of children are attempting to accomplish the same ends by effect-

ing a functional coordination between agencies. The clinic serves the

juvenile court and other agencies and so saves them the confusion of

adding similar services to their own staffs ; the social agency likewise

renders many services to the hospitals and schools. The coordinating

council consists of a council of welfare leaders in a neighborhood de-

signed to bring the various agencies to the attention of those who need

them. Through its appreciation of deficiencies of service in the com-

munity, it is in a position to strengthen existing agencies or promote the

establishment of new ones. This pattern of coordination is entering more

and more into the functions of individual agencies as they seek help from

other agencies as a substitute for broadening their staffs.

The second principle grows out of the first. Since behavior disorders

are determined by a multiplicity of factors, more than can be reason-

ably taken into account in any one program dependent upon human

resources, it is necessary to be somewhat "choosy" if preventive effort

is to be focused for maximum effectiveness. It is, in other words, pos-

sible to waste effort upon relatively minor factors. It is not sufficient to

decide that a certain factor exists, but it must be determined that the

factor is critical, that attacking it will likely change the resultant behav-

ior. Furthermore, a factor must not only be critical but accessible and

vulnerable to attack. A threat of disorder may be found in the death of

a loved one ; this may be a critical factor but not an accessible or vulner-

35] PREVENTION OF PERSONALITY DISORDERS 1171

able one. Furthermore, some factors are more specific than others in

that they result more exclusively in the disorder of personality and

behavior where another factor has broader influence. The removal of the

latter may have bad side-effects. One at least needs to be aware of not

only the desired effects of removing a factor, but also the undesired

by-effects that come from its elimination.

The influence of this principle is especially evident in the way many

child guidance clinics deal with cases that are referred to them. The

child guidance clinic is peculiarly designed to deal with the psychopatho-

logical problems of childhood. It is, therefore, essential that it work

with cases in which this factor is critical, accessible and vulnerable. The

information accompanying the application on an initial diagnostic study

may show that one or more of these requirements are missing : the prob-

lem may be primarily sociological ; or if psychopathological it may not be

accessible for example, as often occurs in court cases, the child and

his parents may oppose treatment ; or it may not be subject to therapy

as in the case of mental deficiency or epidemic encephalitis. The clinic

then devotes a minimum of effort to such cases.

As a third principle, it is necessary to distinguish between the essen-

tial characteristics of a disorder, the aspect that makes it a disorder,

and the unessentials which may merely represent human differences.

There is no virtue in merely removing human differences. There is, for

example, a tendency on the part of some to think of habits as disabling

in themselves. There are habitual drinkers who, however, arc not prob-

lem drinkers, so that the habit of drinking is not of itself a disorder.

A preventive program must take this sort of distinction into account in

focusing its effort if it is to avoid opposition.

Those who adhere to the regimentation of the children in a class-

room think of the active classroom as disorderly because they have never

separated orderly from disorderly activity. The failure to make this dis-

tinction deprives children of a spontaneous function that can contribute

much to their mental growth. Similarly, child labor is not essentially

bad, but is criticized because its unfortunate accompaniments are so

difficult to control separately. A study of children of the dramatic stage

by Zimand (1941, p. 94) has brought this out clearly. It is the pressure

of the children's parents for high performance in a highly competitive

field that is the real problem.

A fourth principle depends upon the fact that many behavior dis-

orders are circular. They stand in a series of events wherein the opera-

tion of one factor leads to subsequent factors and these in turn enhance

the first. To attempt to deal with the original factors in such a circular

series is bewildering and often futile, because the original factors may

no longer be active and better opportunity to break into the vicious

circle may be found at several other points in the course. Opportunistic

interruption of such circular processes at any critical point is often the

best solution. One may kill the chicken or break the egg without decid-

ing on their relative priority.

H 7 2 PERSONALITY AND THE BEHAVIOR DISORDERS [35

One need not go far for concrete examples of this circular effect.

A simple instance is the effect of fatigue. Whatever its original cause

may have been, fatigue reduces the efficiency of behavior. Mistakes and

extra motions are much more abundant. To accomplish the same work

when fatigued more energy is consumed and further fatigue is thereby

induced than in the case when one is rested. Thus fatigue is serious

when one is working on such a narrow margin of reserve that he can-

not take time out to rest. Anxiety and loss of sleep may enter into this

vicious circle to further complicate it. Increasing one's margin of reserve

by decreasing the load of work, taking rest or getting sleep, may, any

one of them, break into this vicious circle. In another case a child who

is caught in the circle of a parent-teacher conflict may enjoy an inter-

ruption of the circle by transfer to another school. Camping programs,

vacations, special residential schools, often without awareness, cut across

such circles that include home and neighborhood problems.

A fifth principle depends on the fact, as emphasized by Tiebout in

1932, that the primary causes of a disorder are often fortuitously or

otherwise solved, but the disorder lingers on by virtue of secondary

factors that did not exist at the beginning. It may be too late to do

anything about the original causes; they may be no longer accessible;

they may be no longer critical ; but still preventive processes may be set

up to weaken the influence of these secondary factors. Stealing that was

started for revenge is impossible to prevent on that basis, after the attri-

bute of revenge is resolved. The continuance of the stealing for the sec-

ondary values derived from the use of the booty may be attacked.

The sixth principle emphasizes the greater promise of preventive

effort applied at an early stage in a disorder. This assumes that habitu-

ation and secondary factors have entered less into determination in the

beginning than would be the case later. This may seem somewhat con-

trary to the concept of disorders as being more or less self-limiting as

Cabot (1934) conceived of delinquency. It is likely that both are valid

and have to be taken into account in prevention. In other words, the

alternative to early stage prevention is not necessarily progressive dis-

order, and this self-limiting possibility needs to be nurtured in instances

in which the early treatment fails.

A great many of the programs that are designed to prevent behavior

disorders are based upon the early discovery and treatment of the dis-

order. The visiting teacher who provides social case-work for children

whose behavior or achievement is unsatisfactory provides a quick serv-

ice on early cases. The special programs for mental deficiency likewise

provide appropriate education at an early period of behavior deviation.

Special programs for truants sometimes provide study and treatment at

an early stage, but all too often they apply pressure for attendance with-

out understanding. Professional education is more and more tending to

include preparation for handling early cases as a part of the routine of

social work, medicine, theology, teaching, and public health.

The seventh principle is based on the fact that our language by which

35] PREVENTION OF PERSONALITY DISORDERS 1173

we label causes and disorders is insufficiently rich to give the distinc-

tions needed between the various grades of disorder. Stealing and lying

cover a great diversity of very different disorders and some behavior

that is not disorderly. There is a tendency to consider certain circum-

stances as either "good" or "bad" in themselves. What is needed is a

many-valued concept of these factors as they relate to modifiable cir-

cumstances. Then by focusing the preventive effort on the circumstances

under which it may operate, the more desirable of the values can be

secured for a factor. The time (date), location, and variety of the factor

have to be taken into account if preventive effort is to be focused effec-

tively. It can then center on reducing those factors that constitute a

greater threat or building up of those of greater promise. Some police

programs designed to prevent delinquency aim to catch the delinquent

early and give him special treatment. Unfortunately, these are too often

law-centered rather than child-centered. A second appearance labels a

child a second offender, and he is dealt with as such even though his

record may be merely as a witness or based on unsubstantiated charges.

The child who rides a bicycle on the sidewalk or plays ball in the street

is equated with the more antisocial on the basis of law rather than the

dynamics of behavior. These are verbal pitfalls.

As an example of the eighth principle it may be stated that appar-

ently, paradoxically, in many cases one does not prevent a disorder by

setting out to prevent that disorder. Rather he seeks the positive devel-

opment of behavior in terms of its value to survival, satisfaction, and

productivity. By reversing the focus from prevention to human enrich-

ment one has by no means abandoned prevention. Accordingly, behavior

disorders are prevented by focusing effort on proper educational goals

in the school, by fostering an understanding of child development in the

home, by health service, by good foster home placement in the case of

dependent children, and by providing attractive play in the recreational

facility and integrating activities of community clubs and parks.

In brief these principles are :

1. Behavior is multi-determined and involves many factors.

2. Preventive effort should be centered on the critical, accessible,

vulnerable, specific factors.

3. The essentials aspects of a disorder should be separated from the

nonessential.

4. Circular disorders may be attacked opportunistically rather than

by historical sequence.

5. The perpetuation of disorder is often less related to its original

causes than to the intervention of secondary causes.

6. Early treatment tends to be more promising, but some disorders

apparently run their courses spontaneously.

7. Confusion in focusing preventive effort is reduced by a many-

valued orientation.

8. Prevention is often a by-product of an effort to develop positive

assets.

ii 7 4 PERSONALITY AND THE BEHAVIOR DISORDERS [35

These eight general considerations clarify the opportunities to pre-

vent disorders of personality and behavior and should be kept in mind

in formulating any program of prevention. Prevention is necessarily

directed toward the aspects of human functioning that are critically

related to disorders. It cannot, however, await symptoms. It must seek

to bring about optimum conditions in these spheres directly, for dis-

orders are so various that to focus attention on prevention of various

symptoms would be disconcerting and scattering. In other words, in

prevention attention must be centered directly upon insuring to persons

the best possible endowment at birth, upon insuring the soundest pos-

sible physiological functioning, especially in certain directions, upon the

development of useful attitudes and habits, and upon affording a whole-

some environment and experiences. These are the foci of preventive

effort. These four foci are, of course, an academic division of the per-

son, for actually these foci can seldom exist in isolation as a program.

Nevertheless, they are useful concepts because they allow us to deal with

some considerations that apply specifically to each of them.

Eugenical Prevention. Eugenical prevention includes all efforts

directed toward the best possible prenatal endowment. These include

good heredity, good embryonic and fetal development, and safe passage

through the processes of birth.

The application of measures designed to terminate adverse heredity

influences have absorbed practically all of our interest in applied human

genetics. The sort of positive breeding that is found in husbandry is

almost unknown. The measures used to influence heredity include the

control of marriage, sterilization, limitation of conception, and destruc-

tion of the embryo or fetus (abortion and miscarriage). Of these the

control of marriage has been left largely to individual private decision,

although of recent years legal statutes have been passed to obstruct

precipitous marriages and to eliminate parenthood among those who have

been so incompetent socially as to require guardianship. This is espe-

cially important in the case of the mental defective. Sterilization of men-

tal defectives has been legalized in a number of states and in the case

of Virginia has been declared constitutional by the Supreme Court of

the United States (James E. Hughes, 1940). The chief scientific argu-

ment against sterilization, namely, uncertainty concerning a hereditary

basis for mental deficiency, applies especially to the high-grade mental

defective who is at the same time the most abundant and the most likely

to reproduce. This approach is, therefore, very limited.

The hereditary factors in the case of the psychoses or even epilepsy

are so uncertain as to cast doubt upon the desirability of any general

rule, although in special cases the evidence of heredity as a major factor

is very strong. The genetic factor in crime is even less evident. Problems

of social inefficiency due to apparently hereditary intellectual limitations

that are still above the level of mental deficiency (that is, the border-

line and dull portion of the population) are not generally considered at

35] PREVENTION OF PERSONALITY DISORDERS 1175

all appropriate for eugenical prevention. In other words, the prevention

of inheritance is most easily exercised in the severe cases that are in

fact fewer and less likely to reproduce. The limitation of conception in

so far as it is dependent upon artificial contraceptive devices is subject

to legal regulations varying from state to state, some encouraging, others

discouraging the practice. The Birth Control League of America is a

special source of information on this subject. Induced abortion or mis-

carriage for eugenic purposes is quite generally prohibited and usually

constitutes a serious criminal offense. It is hazardous for the woman.

It must be realized that the control of heredity involves processes

about which there are deep feelings on the part of the public due to

moral and religious scruples, prejudice, resistance to any encroachment

upon the discretion of the individual in a vital matter, and theoretical

loss of valuable persons to society. If this were not the case some doubt-

ful questions might be answered by experimentation. These attitudes

of society expressed in laws are just as real, just as demanding of respect,

but also just as appropriately subjected to attempts at modification as

other biological limitations.

Preventive efforts directed toward the avoidance of accidents to pre-

natal development and during the process of birth are generally included

in good obstetric practice rather than some specific preventive program

related to personality and behavior. Special attention should be called

to the need to exercise special caution in irradiation of the pregnant

woman with X-ray, particularly in large doses, early in pregnancy.

Serious brain aplasia and idiocy have too frequently followed such irra-

diation.

Recent studies by Fries (1937) have shown the importance of deter-

mining the parents', particularly the mother's, attitude toward her preg-

nancy and the prospective child and of beginning treatment if necessary

so that adverse attitudes may not become a distorting influence in the

life of the child. This is really not a prenatal influence on the child, but

bears mention at this point. Similarly in need of treatment is the atti-

tude of parents and others who have adopted a fatalistic viewpoint

toward the inheritance of specific behavior characteristics, who therefore

expect difficulties in children born of a parent with a disorder of per-

sonality or behavior. Turning attention from the child to the parent, it

might also be pointed out here that the disturbance of behavior in some

women that recurs regularly with each pregnancy or delivery may be

serious enough to necessitate the avoidance of pregnancy or even clinical

abortion.

Physiological Prevention. Attempts to prevent disorder through

the enhancement of physiological function centers on the satisfactory

development and protection of the tissues, organs, or systems of the body.

Some of these physiological areas are more important than others in

respect to their probable influence on behavior and personality. Some

physiological functions are especially general and widespread in their

ii;6 PERSONALITY AND THE BEHAVIOR DISORDERS [35

effect on the body. For example, when heat regulation breaks down,

delirium is apt to result. This is extreme, of course, but lesser disturb-

ances attend lesser deviations in these general functions. Fatigue, insuffi-

cient sleep, poor nutrition, variations in atmosphere, smoldering infec-

tions, inadequate convalescence from illness, disordered metabolism and

oxygenation, vitamin deficiency, endocrine imbalance, allergies, altera-

tions of blood content, circulatory disorders, and disturbances of smooth

muscle function, all have their concomitant disturbances of behavior and

personality and these may at times be major considerations. Unfortu-

nately, these physiological disorders often operate at subclinical levels

that are not taken seriously by the physician because they do not involve

acute or very evident incapacity. These disorders, however, presumably

affect the efficient functioning of nervous tissue. It is apparent that those

who deal with disorders of personality and behavior should be compe-

tent to detect and treat these physiological disturbances. The considera-

tion of these subtle influences needs to be given more serious attention

in medical education if the best preventive opportunity is to be grasped.

There are, in addition to these subtle influences, detectable disorders

of nervous tissue and the sensory and motor apparatus upon whose

integrity orderly behavior is dependent. It is well recognized that sen-

sory deprivations, particularly those of hearing and sight, result in con-

strictions of behavior and personality sometimes resembling mental de-

ficiency. In addition, however, these defects along with crippling act

psychogenically in distorting personality, and so those who are handi-

capped in any way require special protective attention. Disorders of

brain tissues are so frequently associated with general medical prob-

lems syphilis, meningitis, encephalitis, accidents, poisons, pellagra that

their prevention becomes a part of good medical care. Caution in the

use of drugs, encouragement of regular health examinations, the pre-

ventive and treatment programs in the field of industrial hazards, sight,

hearing, venereal disease, public safety, and alcohol, therefore, are an

important part of the prevention of behavior and personality disorders

from both the physiological and the psychological standpoints. Disorders

attendant upon arteriosclerosis and senility are only partially dependent

upon organic brain changes. In part they are a response to the early

handling by the family of the failures of capacity that grow directly out

of the brain damage. In this respect they are to a degree preventable

through wise counseling of the family by the physician and careful regu-

lar health supervision of the aging person.

It should not be forgotten that the integration of the person results

not only in his behavior's being influenced by his physiological condi-

tion, but also conversely that the functioning of his tissues and organs

reflects his mental state. Hence heart, gastro-intestinal and other organ

symptoms are often early leads to disturbed emotional states and, if

treated in relation to the person's whole life setting, will influence the

disorder of personality and behavior earlier than would otherwise have

been true. These functions may be ; then, in a relative sense, preventive,

35] PREVENTION OF PERSONALITY DISORDERS 1177

It is evident from studies such as Billings (1941) that general medicine

stands in a highly important, potentially preventive, position if the patient

as a person is taken into account along with the best that scientific medi-

cine has to offer his body. Dr. W. A. White used to tell of the case of

the pianist who broke his collarbone. His surgeon, making no distinc-

tion between men, had a set procedure for treating such fractures, a

procedure that would insure a good bony union of the parts. This treat-

ment necessitated the immobilization of the arm until healing had oc-

curred. This immobilization so stiffened the hand of the pianist that his

art was greatly impaired. No attention was given to the fact that the

pianist's profession did not demand the perfect union of the collarbone

that a stevedore's work would demand.

Psychological Prevention. Attempts to prevent disorders by safe-

guarding the development of healthy attitudes and habits must always be

executed in conjunction with physiological and social preventives if they

are to be practical, since both of these react upon the person in creating

his psychological composition. Fear, bigotry, suspicion, prejudice, fanati-

cism, moodiness, shyness, stupidity, and many other disabling personal-

ity characteristics are not disorders in themselves; nevertheless, they

are legitimate starting points for preventive work, for they indicate not

only the rough roads of the past that may be smoothed, but they stand

as threats to the future.

Careful guidance in the formative years is a particularly important

phase of psychological prevention. This does not necessitate an anxious

aggressive effort to avert disaster, but rather a calm observation of the

processes of growth in order to see that the inevitable problems of living

are being met successfully. Cuddling a child and allowing him to suck

seems to be conducive to his development in so far as they do not rep-

resent pathological needs on the part of the mother. The child or

youth needs affection as a sign of his worth (Levy, 1937), particularly

as he is so seldom now a financial asset to his parents. In late infancy,

enuresis, eating disturbances and perhaps thumb-sucking, stuttering, con-

fused handedness, and many other transitory behavior phenomena are

certain to appear. It is not so much a matter of preventing them by

prompt assault as of seeing that the usually successful handling of them

by the child himself is taking place, and that the general conditions of

the child are conducive to stability and calm.

Prevention of such activity may prevent some problems, but it denies

the child a freedom essential to his growth and so affords greater hazards

in another direction. Sometimes unusual problems emerge from unusual

experiences rather than unusual make-up. There is still, as a rule, an

inherent adjustability that may be given its chance through a kind con-

sistency on the part of the parent before injecting a new constraining

force into the shaping of the personality.

The handling of the anxiety and neuroses of the parent (Fries, 1937)

is a major function for those who are helping the family in its guidance

1178 PERSONALITY AND THE BEHAVIOR DISORDERS [35

of the child : the doctor, the minister, nurse, and teacher especially. Such

behavior deviations in a parent are the more distorting the smaller the

family, and as the diluting influence of other personalities in the situa-

tion is reduced. Easing of the situation is even more important to pre-

vention as a rule than advising some direct action aimed at modifying

the behavior of the child, behavior that the resources of the child itself

may be sufficient to cope with if given a chance. This is especially

important when the parents' anxieties center on what they consider sex

deviations, chiefly because parents are often unable to think calmly in

that sphere. If the parent regards the child as a sexless creature, sex

expression, such as masturbation, becomes an "abnormality/' and out of

it there can be no sane guidance toward satisfactory sex development.

If the parent is upset about sex, the child is not helped to the kind of

sex orientation that is neither too highly charged emotionally nor yet

so thoroughly objective as to be unreal. Mature mental adjustments

cannot be expected to grow out of an unrealistic concept of the sex

function. Youth is faced with a real problem in the discrepancy between

physiological and cultural maturity. Most youths handle this five- to

eight-year discrepancy fairly well, but unless this discrepancy is seen as

a burden on youth, other burdens may be imposed by parents and others

to the point of collapse.

It is necessary to recognize that children are confronted with a con-

tinuity of extrinsic experiences, unpredictable and uncontrollable, some

of which tend to contribute to adjustment and some of which tend to

act otherwise. In spite of these usual tendencies, certain experiences

usually regarded as destructive may under the right conditions turn out

to be beneficial. Moreover, "good" experiences may prove to be the

opposite. There comes about then a progressive individuation, a devia-

tion from the rule without reference to which no "preventive" effort is

assuredly good. At no time is sound behavior finally assured. At any

time unhealthy reaction tendencies may be turned to advantage. In gen-

eral, however, there are certain desiderata (Stevenson, 1941) conducive

to good behavior and these form the basis of a practical program. One

needs, however, a readiness to devise a specifically designed procedure

when individual peculiarity shows the unappropriateness of the general

approach. Usually it is good to insure a breadth of human and experien-

tial contacts and satisfactions and to allow opportunity for airing one's

feelings. It is a part of growth and developing strength to experience

the security and the affection of family life and the assurance of this is a

real preventive.

Automatization within limits is essential to the economy of behavior.

Essential also to security and tranquillity is a margin of safety between

capacity and the demand made on personality and behavior. This is

important in school and work. Among the important automatizations,

there are many essential habits such as habits of work, habits of human

relations, habits of using one's talents and abilities, and habits in the use

of one's hands. It is a part of growth to play, not only for the purpose

35] PREVENTION OF PERSONALITY DISORDERS 1179

of using muscles and increasing experiences, but also to soften and get

perspective on and give vent to some of the inevitable disappointments

of life and react to the limitations that come from a social way of life.

Play is a way of redirecting and sublimating aggressions that otherwise

lead to trouble. The emancipation of the child should be a gradual proc-

ess, a culmination of growth beginning at birth rather than an episode of

the late teens. As with play, a vocational goal is an integrating core

about which to orient experience during early development, and it is use-

ful, whether realized or not, in future work. Similarly, a philosophical

construct, religious or otherwise, may act as a nucleus about which the

individual can so interpret his lot in life as to achieve better personal

organization.

Just as gastric or cardiac disturbances may be recognized as early evi-

dences of mental burdening, so excess pressure may bring to evidence

attitudes and habits that would otherwise remain inactive. These are

signals for attention and their persistence is a signal for doing something

about them and possibly the pressures that induced them. Emergencies

such as war and imminent danger or threat are especially potent in mag-

nifying such weakness and may be used to advantage in revealing the

need for prevention. It is for this reason that selective service, employ-

ment and personnel systems, economic stress, school tests, examinations,

and competitions often bring problems to light. These pressures aug-

ment anxieties, sensitivities, social isolations, inferiority feelings, sleep

disorder, tics, conflicts with authority, evasions, aggressions against

others, obsessions, indecision, temperamentality, speech disorder, and

many other aspects of human discomfort.

Insight relative to these behavior tendencies is an important consid-

eration in strengthening the person against their negative aspects. But

insight itself is not altogether assuring, for it may either create new and

usable perspectives or engender devastating anxiety. Insight must, in

other words, be timed with the readiness of the person to use it. It is

valuable to be aware of the fact that certain situations tend in certain

people to precipitate serious progressive or circular behavior processes

culminating in mental disorder. Insight properly timed has in such cases

potentially a distinctly preventive value.

There are those (Harrington, 1938) who claim that, in the face of

transient severe pressures, "playing a role," making believe that things

are different from what they are, assuming postures of confidence, are

sufficient to tide over the emergency and avert a break. In some cases

this seems to be true, in others not. The indications for its favorable

employment are not entirely clear.

Handling these potentialities for disorders that are so protean in form

may demand joint action on the part of several functionaries, i.e., sev-

eral community agencies. A good example of such joint action is the

work of the visiting teacher in the public school who solicits joint action

of home and school and insures a greater degree of individualization in

the planning for certain children. In the case of the pupil whose irregu-

n8o PERSONALITY AND THE BEHAVIOR DISORDERS [35

lar attendance constitutes a problem, the visiting teacher's first contact

may be either with the attendance department or the classroom from

which the case is referred to her. With these two departments she main-

tains collaboration throughout her study of the case. However, studies

are then extended into the community aiming to elucidate the factors that

may be found in the home and neighborhood. Recreational agencies are

of special interest in this connection. Very frequently this brings the

visiting teacher also into cooperation with relief and social case work

agencies, since truancy is often associated with economic and family dis-

order. At other times the public health or visiting nurse organizations

provide clues to her case or collaboration in its treatment. Should the

problem be of long duration, it is apt also to lead to the juvenile court

and probation department. Thus it is that one child becomes the nucleus

of integration of agencies who are concerned with the problems behind

such disorder and agencies who are occupied with its various expressions

and its therapeutic attack.

Social Prevention. It is evident from the foregoing that it is diffi-

cult to separate psychological and social efforts at prevention since,

unless the person applies all psychological preventives to himself, they

require someone or something in his setting to bring these about. The

melioration of the setting of the individual in order to facilitate his men-

tal and emotional growth and avoid entirely baffling situations is as broad

as living itself. The home life, education, work, health forces, religious

resources, play facilities, economic situation, friends, and requirements of

law, all have their plus and minus values in helping or hindering in the

development of personality. Completely baffling situations result in no

success and no progress and are conducive to regression, whereas diffi-

cult but solvable situations have the reverse effect. The meaning or

importance of the setting is, furthermore, seldom absolute, but is merely

another facet of the culture whose values the individual has adopted and

which has become part of his psychological structure. Thus there are

very few fixed values to the setting. A divorce in a Catholic family is

likely to be more disturbing than in a Protestant or Jewish family. It

may be said that, in general, the mores of a group are time-tested and a

fairly safe guide to what an environment should be. But this is not

always the case, for mores hold on long past the conditions that created

them and may be the basis of serious disturbances of personality and

behavior. Furthermore, it is obvious that, while there are very likely

common basic elements in the various religious formulations, the differ-

ences between them that men fight for show that they are not attuned

to identical psychological needs. A certain religious formulation may

become a great stabilizing force for one person, but it may become just

the opposite for another. That these psychological needs are not fixed

patterns is evident from the religious changes that accompany altered

social conditions of certain immigrant groups. Religious conversions

based on conformity to group attitudes or individual pressures must be

35] PREVENTION OF PERSONALITY DISORDERS 1181

evaluated with caution, for the formulation given up may have greater

values than the one into which the convert is swept.

Home life is the keystone of emotional satisfaction and growth. At

best, it affords guidance for the child in working out solutions to the sit-

uations in life that irritate him so that irrational aggressions may not

burst forth from time to time to interfere with his effectiveness and spoil

his happy relations. At worst, it can overbalance the fortunate effects

of most other types of experience. Nagging is a frustration that aggra-

vates either a child's anxious retardation or his hostile aggression. Paren-

tal overprotection is constricting to his experience and contributes to the

impoverishment of his behavior resources. Habit training gives him use-

ful automatizations that release his behavior resources to meet new prob-

lems. Affection and physiological satisfactions give him strength and

security to move into new experiences. Neurotic parents and teachers

tend to force him to adjust to their atypical patterns which are crippling.

Where a member of the family is neurotic, it is well to allow for rich

contacts with better patterns of personality.

Education of parents is a help in meeting some of these needs of family

life, but to be effective, such education must emerge from experience

with feeling instead of from words, phrases, rules, or principles. This

means that parent education must help the parent benefit by home life,

and out of that the child will gain. A preventive effort for the one

accrues undesignedly to the other. Thus the mutual sex adjustment of a

couple is a prophylactic not only for them but for the whole household.

The schoolroom is in a way a counterpart of the household. The crux

of the classroom is the life adjustment of the teacher. The school is at

present of value in revealing opportunities for preventive work, for the

school subjects the child to two important pressures that are likely to

bring out his need for strengthening his mental resources. First, the

school is as a rule the first gross break from the home, and the child's

capacity for progressive emancipation is reflected by this and strength-

ened or weakened by the way it is handled. The nursery school and kin-

dergarten are two adjuncts to the usual school pattern that ease the child

into this break and at the same time maintain a little closer touch with

the home. Second, the school subjects the child to the repeated necessity

of applying what he has learned either in giving him work to do that

uses it or in formal testing of his knowledge. The former of these tries

out his capacity to integrate his knowledge into action, the second chal-

lenges his resilience in meeting a threatening situation. Unfortunately,

many schools have not the personnel such as visiting teachers or school

social workers to use the leads offered by those strategic situations. It

is, of course, necessary to keep the school's responsibilities within the

boundaries of the school's job and not expect it to be a psychiatric clinic.

Still there are certain activities the need for which is inescapable and

which no other agency is situated to deal with. The child is living in the

classroom. Unless his interests and ambitions are somewhat appreciated,

unless he can be somewhat individualized, unless his work is somewhat

n82 PERSONALITY AND THE BEHAVIOR DISORDERS [35

related to the future through vocational guidance, unless in short his life

in the classroom is both useful and satisfying, there are likely to be seri-

ous gaps in his development. Some children reveal themselves differently

at different times to different teachers or different subjects or differently

as between school and home. This inconsistency is a lead to be followed,

a fluid state, a state that is on the one hand more vulnerable and on the

other more promising. Bios (1941) has shown how these fluctuations

are related to the existing or potential disturbances in personality and

behavior. Leaders in the educational field have clarified these opportu-

nities but they are blocked by many deeply rooted traditions within the

school system and by public attitudes toward the school.

What the school is for the child, work is for the adult. It is the final

test of emancipation, of integrating the preparatory training and experi-

ence into creative interest. At the same time, work is an instrument for

gaining food and shelter and the money for essentials. Unless work life

fills the needs of the person, it is permitting deficiencies in his mental

life that have as serious impact as deficiencies in his diet. Monotony of

work that fails to challenge the potentialities of the person has danger

unless compensated outside of work life. Insecurity of work finds an

important compensating preventive in unemployment insurance. Poten-

tially industry has somewhat the same opportunities for testing the

worker and instituting preventives as the school, but it is only beginning

to discover that the objectives of industry are not at odds with the

enhancement of personality and efficient behavior of the employee (Burl-

ing, 1939). The school may be expected to be to a degree parental, but

according to a democratic way of life, employer and the employed must

find a different basis for mutual helpfulness.

With growing attention to the insurance of economic security and the

mechanization of industry, the deficiencies of work life need more and

more compensation in play and companionship. Like religion, the dif-

ferent forms of play and companionship are fundamentally dependent

upon common essentials, but in form they differ so from person to person

that in order to satisfy the peculiarities of the individual, a wide diversity

of opportunity is necessary. There is danger in the tendency to think that

the form that is successful in giving satisfaction to one person reflects

something inherently good that commends an avocation to all persons.

Play is a deep influence exerted at an unconscious level that necessarily

depends upon the peculiarities of the individual.

One cannot face the fact that a large part of the problems encountered

by any doctor grow out of personal and situational disorder without

accepting the importance of the medical and health fields in a preventive

effort (Billings, 1941). The more serious psychiatric disorders can often

be sensed and treated early by an alert general practitioner, especially if

aided by psychiatric facilities in a general hospital and voluntary admis-

sion provisions for the mental hospital. The existence of psychiatric

practitioners in the community (social psychiatry) not only facilitates

the early use of psychiatric treatment, but brings the medical practitioner

35] PREVENTION OF PERSONALITY DISORDERS 1183

of the community into close touch with that specialty, to their own enrich-

ment and the benefit of their patients. Medical social service as an

adjunct of the general hospital also greatly facilitates and clarifies the

need for treatment of personal and situational issues before they become

overburdening. The physician should consider abnormal emotional states

anxiety, resistance, lack of cooperation, etc. as liabilities to be treated

rather than obstructions to be railed against.

One of the important developments aimed at prevention of personality

and behavior disorders is the child guidance clinic. This is a psychiatric

clinic with associated psychological and social service. While it is impos-

sible to say how much actual prevention of mental disease and delin-

quency results from the services of these clinics, there is little question

that they contribute greatly to the mental health of the children they serv-

ice. According to Stevenson and Smith (1934), about three-quarters of

the children seen by such clinics are improved as to personality and

behavior. The indications are that school failure is often averted.

Whether one subscribes to Freudian concepts of causation or not, Witmer

(1940) points out the common sense in beginning early with prevention.

It is evident to anyone studying the records of these children that the

greatest promise lies in a broad attack involving the many potential and

actual community influences that bear on the child. It is also evident that

every community agency dealing with children encounters opportunity

for preventive work in the course of routines that would not be open to

anyone else. Some of these agencies are pointed toward handling prob-

lems, others carry preventive effort by pointing their work more directly

toward life well lived.

Leaders in the field of psychiatry have long envisaged plans in which

those individuals and institutions in position to have a full perspective

concerning the serious personality deviations and their determinants

should contribute their fullest effort in providing or fostering preventive

work. Our state institutions for the mentally sick are in such a position,

but, unfortunately, they are so bowed down by traditions and restrictions,

as are also the schools, that outside help is needed to enrich their pro-

gram beyond its present confines. On this account Witmer questions the

value of these institutions in sponsoring preventive work and seems in-

clined to look more favorably upon health departments.

Modification of laws is necessary to the realization of some preventive

possibilities. Again and again, the forward movement of these established

agencies toward greater preventive effort is obstructed by laws limiting

the scope of their staff and their other resources. In other respects, laws

that are unsuited to the situation bear upon everyone, encourage dis-

obedience and engender disorder. There is an inevitable lag in laws, but

at times the courts and the legal profession fail to take advantage even of

present possibilities. Many juvenile courts continue on a criminal basis

after the law allows otherwise. They suffer the same inertia as the gen-

eral practitioner of medicine toward translating the glaring evidences of

need for certain action into such action in the face of habit to the contrary.

1184 PERSONALITY AND THE BEHAVIOR DISORDERS [35

These changes demand public pressure, emanating from those most seri-

ously affected, and voluntary financial support of demonstration and

education until new processes can be established.

Projects Designed to Prevent Disorders of Personality and

Behavior

Professional preparation and training for work in the various fields

strategically situated to prevent disorders of personality doctors, nurses,

lawyers, ministers, social workers, teachers are essential to a widespread

and effective preventive effort. Extensive projects, even without this

backing, have been organized and are functioning. These projects are

often motivated to prevent some specific type of behavioral difficulty

mental disease, delinquency, dependency, school failure, conduct disorders

but as a rule, if they are valid for the one type of disorder they are to

a high degree valid for other types. The Gluecks (1936) have brought

together a large number of descriptive statements about such activities.

Undoubtedly some of these are effective for unknown reasons so one

must do considerable "reading between the lines" in evaluating any proj-

ect designed to prevent personality disorders. An elaborate process of

dealing with a child may be successful because of some incidental change

of environment or because of some change at home.

The Gluecks (1936) have laid down certain principles of crime pre-

vention which, for the most part, are applicable to all forms of person-

ality and behavior disorder. In brief they are :

1. Crime-prevention programs should take into account the evidence

that most criminals show definite antisocial tendencies of atti-

tude and behavior early in childhood.

2. In most instances, children should be kept away from police sta-

tions, courts, and correctional institutions until more scientific

and sympathetic efforts have failed.

3. An experimental attitude should govern the establishment and

conduct of crime-prevention programs.

4. It cannot be definitely concluded as yet that any one type of

crime-preventive activity is necessarily superior to, or should

be exclusive of, any other.

5. Existing community agencies and institutions should be used to

their fullest capacity.

6. While much good can be accomplished by whatever qualified

agency in a community assumes the leadership in crime pre-

vention, the public schools can play an especially significant

role.

7. Although not indispensable, a crime-prevention bureau in a police

department has certain unique values.

8. Crime-preventive efforts should be discriminating in technique.

9. Crime-prevention programs should recognize that children must

have ample outlets for their energies.

35] PREVENTION OF PERSONALITY DISORDERS 1185

10. Other psychological and behavior traits of children should be

taken into account in planning and carrying out crime-preven-

tion programs.

11. Intensive work with problem children and delinquents and the

attitudes and prejudices of parents should not be ignored.

12. Trained personnel should be liberally employed in crime-preven-

tive activity.

The Gluecks (1936) also present a description of the specific projects

aimed at preventing disorders. Each of these has been described by some

person closely associated with the project. Some of these stories are more

biased and less objective than others; many are adjusted to peculiar

local situations ; yet all have elements that may be worked into a program

elsewhere. They give a fairly complete perspective on efforts to prevent

behavior disorders. The first group of papers deals with programs for

community coordination.

In the Los Angeles County Coordinating Council Plan, a program is

described that provides for the counseling of the welfare leaders in a neigh-

borhood. This program is designed to study, educate, and organize the

various agencies in a neighborhood, and to bring to their attention those

in need of their services. Kenyon J. Scudder, who contributes this story,

might have improved it by "telling on" a few of his own delinquent progeny :

those coordinating councils that try a hand at case-work, or those that

tend to fall asleep on the job. In spite of these omissions, however, he is

modest in his claim that the project has helped to make the community a

better place in which to live

In the Lower West Side Crime Prevention Program, New York City,

Frederic M. Thrasher presents a modest, critical, scientific approach. It

involves a great many diverse activities relating to the many causes of

crime, and hence makes a less brilliant showing than some of the more

intensively focused programs. Its very breadth is realistic, however, being

postulated on small general gains rather than on narrow, concentrated

results.

The Foundation for Youth in Columbus, Indiana, by Walter H. Hall

and Robert K. Atkinson, discusses a program that is motivated not spe-

cifically toward crime prevention, but toward the satisfaction of the self-

evident need of youth for opportunities to play. It has, consequently, no

exaggerated promises to live up to. The efforts of this foundation, which

are centered on a boys' club, are coordinated with all the other leisure-time

services in the community through a joint director.

In the Director-at-Large Plan of the San Francisco Recreation Com-

mission, a plan is outlined for giving boys individual attention, getting them

to the right agencies, providing them with constructive experiences, and

supplying advice. The success of this plan obviously depends upon the

selection of personnel for enthusiasm, critical technical service, and full-

time application. Gerald J. Linares, the author of the paper, could undoubt-

edly have done better in pointing out the weaknesses of his program.

The next group of papers presents six school programs of importance

In the prevention of delinquency :

n86 PERSONALITY AND THE BEHAVIOR DISORDERS [35

In Character Building for Crime Prevention in Public School #181 in

Brooklyn, Dr. Nathan Peyser presents a plan based upon an educational ap-

proach so fundamental that the prevention of delinquency may be naturally

expected to result. The schools have an opportunity, not only in their own

sphere, but through their community relationships, to influence character

development and to serve as centers of community morale. In this instance,

the school became the nucleus of coordinated effort in the community. It

undertook community surveys and organizations to meet community defects.

It had a paid professional staff, a case-adjustment service, a Big Brother

phase, and projects in the field of recreation and of adult education. Dr.

Peyser expressly states that it is all experimental.

The Bureau of Special Service in the Jersey City Public Schools, by

Thomas W. Hopkins, is the account of another plan under which the schools

have assumed leadership in community coordination as well as supplying

special services clinical, visiting teacher, and the like. The point of view

of the paper is promotional; no problems are described, and there is some

evidence of competitive feeling with regard to the coordinating-council

procedure.

The Visiting Teacher in the Cincinnati Public Schools, by Ethel Reyn-

olds, is a clear, dispassionate presentation with no exaggerated claims.

Emphasis is laid upon the fact that the visiting teacher is in essence a case-

worker. She brings into the educational system a flexibility that is beyond

the range of the classroom teacher. In spite of this, the requirements for

the visiting teacher are primarily educational and are only secondarily those

of a case-worker.

Dr. Henry J. Baker, in his paper The Diagnosis and Treatment of Mal-

adjusted Children in the Detroit Public Schools, recognizes the limitations

and defects of his program and faces them squarely. This work in Detroit

shows how much the link in this case the schools needs to be strength-

ened before it is forged into a chain of community agencies, and how one

agency, by sawing its wood all the way through, brings about coordination

of effort between agencies. It also shows how the prevention of delin-

quency may be approached as a by-product of a job well done in some one

field.

The same point is brought out by Meta L. Anderson in The Binet Schools

of Newark. Discussing the development of a high-grade educational pro-

gram for the mentally retarded, she deals with some very personal reasons

for the delinquency of such children. And again one sees how a program

such as this, carried through on a high level, automatically brings about

cooperation between community agencies. The presentation of the program

is modest and critical.

The Montefiore Special School for Problem Boys in Chicago presents

a plan that is more distinctly pointed toward the prevention of delinquency

in that it is designed for truants. The Montefiore School combines the

functions of a special school with some of the services of a child-guidance

clinic. Its curriculum is specially adapted to the needs of its pupils, and

in that respect it is a cross between the Newark program and the regular

educational program, since most of its pupils are mentally handicapped.

Here, too, we see how following through the needs of a special group

brings about a natural cooperation between community agencies. Edward

H. Stullken, who contributes the paper, is modest in his evaluation of the

program.

35] PREVENTION OF PERSONALITY DISORDERS 1187

Two accounts of police-department activities are also given :

The Crime Prevention Bureau of the New York City Police Depart-

ment, by Henrietta Additon, describes a program that has been discon-

tinued. In its original form, it was distinctly a police program, dealing

with minors in the early stages of delinquency and with such adverse com-

munity conditions as are within the reach of a police department. In addi-

tion, it exerted an unofficial influence for community betterment on the

basis of the needs that came to its attention in the course of its work.

Individual problems were dealt with by simple social-case-work procedures

against a background of authority. Some of the bureau's activities were

neglected functions of schools or other community departments. It was

directed by a specially appointed police commissioner, assisted by a large

corps of selected police officers and investigators.

In the Crime Prevention Work of the Berkeley Police Department,

Elizabeth Lossing describes an evolutionary product with an attitude of

critical self-appraisal and a detailed analysis of problems. The plan in-

volved close working relationships with various community agencies, of

which the first coordinating council was a natural growth. High standards

for its personnel have insured the progressive development of this pro-

gram. The work includes service to delinquent adult women, to girls and

young boys, and to children in danger of becoming delinquent; the educa-

tion of lay and professional groups; and participation in community better-

ment and in "upstream work antedating prevention/' A host of activities

along this line includes sports, reading, entertainments, and club work. In

addition, the special bureaus within the police department, the personnel

of the department as a whole, are expected to participate in crime-prevention

work. The evaluation of this program is modest and no excessive claims

are made.

Four intramural programs are presented :

Longview Farm, at Acton, Massachusetts, which is described by Leslie

B. Blades as a study home for problem boys, accepts its clients chiefly from

private agencies boys who have social and personal maladjustments with

which the ordinary foster home is not qualified to deal. The theory behind

the work of the home is that "society itself produces problem children,"

and that the home must offer a more healthful social environment. While

striving to be a typical home, Blades recognizes the fact that the authority

of the study home is social rather than familial, but it avoids imposed study

and treatment and gives the boy a chance to determine his own course,

enjoying or suffering the consequences. Participation in the work of the

home, whatever its nature, is regarded as worthy of respect because of

its social value. The experience is designed to be educative and to develop

an appreciation of social responsibility, justice, and tolerance through the

natural activities of every day.

The Children's Village at Dobbs Ferry, New York, described by George

C. Minard, is another intramural project that is experimenting with the

education of delinquent children. The Village has many advantages through

its long experience and its proximity to the abundant resources of New

York City. Its program is fundamentally designed to give the boys an

opportunity for natural self-expression, with a minimum of restrictions.

The activities of the Village in the direction of the prevention of delin-

ii88 PERSONALITY AND THE BEHAVIOR DISORDERS [35

quency are implied rather than direct, on the principle that a satisfied con-

sumer of our culture is its best customer.

The account of the George Junior Republic, by Donald T. Urquhart,

while it is not promotional in the same sense as are some of the other

stories, expresses an almost overwhelming" conviction. The Republic is an

institution of the cottage type, designed like a village, with small groupings

and divisions of labor. Training for citizenship is its paramount objective.

It includes self-government and an economic program of earnings designed

to teach the various values of property. An attempt is made to duplicate

as far as possible the functions of a normal community and to force the

boy to experience the results of his own idleness and antisocial conduct.

As in the case of an established society, most of the needs of this planned

community have been formulated in rules and laws within which individ-

ualization may take place. This particular account of the program deals

much more with the regulations than with the individualization.

The fourth intramural program is that of the summer camp for delin-

quent boys at Greemvood Lake, Delaware, Ohio. It is described by Irving

A. Wagner. The camp admits boys with behavior problems and problems

of adjustment. It is not restricted to delinquents. It serves as an adjunct

of the court through the appointment of its director to a court office. An

attempt is made to provide such adequate supervision that the spontaneous

interests of the boys will find natural outlets. Both counselors and boys

are carefully selected. The success of the project is estimated with rela-

tive conservatism. Experience has led those engaged in it to feel the

need of a continuation of the work through an interseasonal agency.

In addition to these four intramural projects, jour extramural guid-

ance programs are given.

Dr. Samuel W. Hartwell contributes an account of the Child-Guidance

Clinic of Worcester, Massachusetts. This clinic was the gradual outgrowth

of a state hospital's attempt to serve its community, although at the present

time the community assumes a large part of its support. It serves all the

community agencies, including the court, and thus comes into contact with

the antecedents of delinquency. It selects those cases that are most in need of

its peculiar contribution, which is psychiatric examination and treatment.

Treatment consists of personal direction of the delinquent or potential de-

linquent, directly by the clinic and through the court, probation staff, or

home. Its program includes educational work, aimed at bringing about a

better understanding of delinquency, and attacks upon community conditions

that cause delinquency. Its staff is made up of psychiatrists, psychologists,

and psychiatric social workers, all of whom take part in examination and

treatment; their efforts are integrated through case conferences. The aim

of treatment is to develop feelings of adequacy through a sense of "belong-

ingness" and a philosophy of life. The clinic's attitude toward evaluation

of its work places it among the more scientific and conservative proj-

ects.

The program of the Alfred Willson Children's Center, of Columbus,

Ohio, is presented by Bertha Fulton. This project is a group effort which

employs a psychologist, a social worker, and a physician. While it professes

to be something "more than a child-guidance clinic/' its staff really repre-

sents part of the usual child-guidance staff. It claims to carry on psychiatric

35] PREVENTION OF PERSONALITY DISORDERS 1189

work, but has no psychiatrist on its staff. Its understanding of the child-

guidance clinic is obviously scant. It attempts child-placing, group work,

parent education, and other activities usually carried on as specialized serv-

ices, whereas its staff is confessedly not highly experienced.

The Big Sister Service in Rochester, New York, on which Elizabeth

R. Mertz contributes a paper, carries on a quasi-professional case-work

through volunteers under professional supervision and with professional

assistance. Girls from ten to sixteen years old are referred to it by various

community agencies for help with various types of personal problems of

adjustment.

The Parents School of the Domestic Relations Court of Franklin County,

Columbus, Ohio, is discussed by Erwin V. Mahaffy and Mabel I. Riebel.

It is conducted by a select group of teachers who have been oriented in

the various social fields, and its techniques have been developed experimen-

tally. One of the conditions of probation for a child is that the parents shall

attend this school, and everything is done to make it easy for parents to

meet this requirement. The teaching is simple and to the point, in part

didactic and in part carried on through group discussion.

The final section of the book deals with four instances of boys' clubs

and recreational programs:

The All Nations Boys Club, in Los Angeles, discussed by Charles S.

Thompson, has developed methods and techniques for leisure-time activities

among underprivileged boys. Its work a combination of group-work and

case-work is carried on in the heart of a delinquency area. It provides a

gymnasium, a library, craft work, clubs, games, and other social features,

and conducts a summer camp. It has a small trained staff, which is supple-

mented by selected college students. It tends to estimate its value in terms

of a decrease in delinquency rates in its territory.

The Boys' Club, of Worcester, Massachusetts, is designed to deal with

the neglected boy. While it does not especially advertise service to delin-

quents, it does make a special effort to hold the interest of this type of boy.

It carries on the usual functions of a boys' club, offering a variety of

facilities and supervision. It recognizes that its work is a part of a com-

munity prevention program, and its claims, as presented by David W.

Armstrong, are modest.

Harold S. Keltner outlines the crime-prevention program of the Y.M. C.A.

in St. Louis. This is a project for guiding into constructive activities the

naturally organized gangs found in less privileged neighborhoods. Many

minor deviations of behavior in these gangs are accepted in the effort to

divert them from more markedly antisocial activities. Leadership is pro-

vided, but in the main the clubs depend upon their own resources rather

than upon outside charity.

The program of the Philadelphia Boys' Club and Settlement Project is

presented by Robert C. Taber. This project grew out of an effort to direct

quasi-delinquent boys to community resources that might be of value to

them. This proved to be such a large order for the one person employed

that it was made a special project under a federal program, using un-

trained personnel. An essential part of the program has been the training

and supervision of these workers. Evaluation of this program on a quite

objective an4 critically conceived plan shows significant results.

1190 PERSONALITY AND THE BEHAVIOR DISORDERS [35

While there are obviously great differences in the evaluations of these

programs as well as in the approaches to the prevention of delinquency

that they represent, they provide a useful guide for any community group

that is instituting work in this field. Seldom will it be possible to copy

any of the programs in its entirety, but all of them are suggestive and

offer valuable leads in the organization of a program adapted to a partic-

ular community.

It is evident that these are not specifically projects to prevent delin-

quency, but in fact apply to all disorders of personality and behavior. As

has been previously implied, prevention of disorders of personality and

behavior is often the indirect result of an effort to enrich human living.

Hence it depends upon the improved capacity of those regularly contrib-

uting to such enrichment. The doctor's interest in his patient as a person

needs strengthening. Public health needs broadening so as to be con-

cerned about living as well as mortality and morbidity. Education needs

chiefly to follow the reality of individual differences rather than group

norms, and it needs to enhance the professional feeling of the teacher.

Social work needs to consider not only material lacks, but poverty of the

spirit. Psychiatry needs to break away from the hospital in the direction

of child guidance. Theology must be recognized as a dynamic psycho-

logical construct and a form of personal support as well as a theological

revelation. Recreation must be seen as a potent and deep, but uncon-

scious dynamic force. Industry should be seen as a social effort return-

ing value generally in so far as it affords security and satisfaction to all

involved. Since the persons served by these community forces are never

related solely to any one of them, community coordination of effort i. c

required and it becomes a mutual fortification. Education of the public

is an essential part of the foundation of such community effort, and

without it, such effort is likely to find itself on shifting sands. Human

habits of work and adjustment change relatively slowly, and the cultural

circumstances in which these habits operate may change radically and

rapidly in our industrial age. No preventive effort can ever be consid-

ered permanently fixed and settled in the face of this discrepancy. Pre-

ventive efforts require continuous readjusting. The search for newer

and better methods goes on. It is never ending.

BIBLIOGRAPHY

BILLINGS, E. G. 1941. The value of psychiatry to the general hospital. Hospitals,

15, 30-34.

BLOS, P. 1941. The adolescent personality: a study of individual behavior. New

York : Appleton-Century.

BURLING T. 1939. Personality in the economic situation. Amcr. J. Orthopsy-

chiat., 9, 616-622.

CABOT, R. C. 1934. One thousand delinquent boys. Survey, 70, 38-40.

FRIES, M. 1937. Factors in character development, neuroses, psychoses and de-

linquency. Amer. J. Orthopsychiat., 7, 142-203.

GLUECK S., & GLUECK, E. T. 1936. Preventing crime: a symposium. New York:

McGraw-Hill.

HANKEN, A. H., & ZIMAND, G. F. 1941. Children in the theatre. New York:

National Child Labor Committee.

35] PREVENTION OF PERSONALITY DISORDERS 1191

HARRINGTON, M. 1938. A biological approach to the problems of abnormal be-

havior. Lancaster, Pa.: Science Press.

HUGHES, J. E, 1940. Eugenic sterilization in the United States. Publ. Hlth

Rep., Wash., Suppl. No. 162.

KASANIN, J., & VEO, L. 1932. A study of the school adjustment of children who

later in life become psychotic. Amer. J. Orthopsychiat., 2, 212-227.

LEVIN, H. L, 1933. The role of child guidance in the prevention of schizophrenia

(dementia praecox). N. Y. St. J. Med., 33, 808-812.

LEVY, D. M. 1937. Primary affect hunger. Amer. J. Psychiat., 94, 642-652.

MATHERS, A. T. 1931. Difficulties and problems in the programme for prevention

of mental disease. Canad. publ. Hlth J,, 22, 10.

MEYER, A. 1925. Individualism and the organization of neuropsychiatric work in

the community. Ment. Hyg. t N. Y., 9, 675-685.

STEVENSON, G. S. 1941. Mental hygiene problems of youth today. Ment. Hyg. f

N. Y., 25, 539-551.

STEVENSON, G. S., & SMITH, G. 1934. Child guidance clinics a quarter century

of development. New York: Commonwealth Fund,

TIEBOUT, H. M., & KIRKPATRICK, M. E. 1932. Psychiatric factors in stealing.

Amer. J. Orthopsychiat., 2, 114-123.

WILLIAMS, F. E. 1932. Is there a mental hygiene? Psychoanal. Quart., 1, 113-

120.

WITMER, H. L. 1940. Psychiatric clinics for children. New York: Common-

wealth Fund.

AUTHOR INDEX

(Italicized numbers are Bibliography pages)

(Volume I pages 1 to 618; Volume II pages 619 to 1191)

Abadie, J., 953, 964

Abel, T. M., 245, 246

Abraham, K., 274, 278, 292, 299, 303, 624,

625, 6J t 8, 874, 878, 900, 910

Abt, A. F., 634, 649

Abt, I. A., 634, 649

Achilles, E. M., 1007, 1022

Ackerly, S., 569, 578, 712, 977, 1022

Ackerman, N. W., 242, 246, 289, 302, 684

Ackerson, L., 764, 766, 788

Adams, C. R., 189, 205

Adams, H. F., 153, 157, 166

Adie, W. J., 786, 788

Adler, A., 124, 131, 222, 246, 768, 780,

789, 860, 1143, 1157, 1162

Adrian, E. D., 1034, 1035, 1036, 1037,

1038, 1040, 1043, 1054, 1056, 1087

Agiiero y Montoro, H., 1034, 1087

Aichorn, A., 99, 131, 711, 712, 809, 819,

1141, 1149, 1157

Akimov, N. E., 589, 610

Alberti, J. L., 1041, 1087

Alcoholics Anonymous, 163, 166, 1147,

1157

Aldington, R., 12, 14, 4$

Aldrich, C. A., 88, 131, 655, 684, 1162

Aldrich, M. M., 88, 131

Alexander, E. J., 599, 614

Alexander, F., 113, 131, 217, 246, 256,

267, 269, 273, 274, 275, 276, 277, 278,

279, 280, 281, 282, 284, 286, 288, 289,

290, 293, 294, 295, 298, 299, 300, 301,

302, 304, 327, 329, 535, 546, 584, 610,

809, 810, 819, 931, 936

Alexander, F. M., 1121

Alexander, L., 525

Alice, W. C, 607, 608, 610

Allen, E., 601, 607, 610

Allen, F. H., 687, 773, 788, 789, 1148, 1157

Allen, R. D., 165, 166

Allport, F. H., 9, 43, 192, 208

Allport, G. W., 3, 4, 6, 7, 8, 10, 12, 15, 24,

26, 27, 28, 29, 30, 34, 35, 37, 41, 42, 43,

44, 49, 50, 51, 61, 66, 70, 75, 77, 131,

139, 146, 153, 157, 161, 166, 170, 184,

188, 189, 195, 201, 204, 205, 505, 523,

796, 819

Alper, B. S., 815, 820

Alpert, A., 684

Alstead, G., 722, 733

Altenburger, H., 1036, 1038, 1076, 1091

Altman, C. H., 898, 910, 981, 982, 984,

1022

Altman, M., 608, 610

Altmann, L. L., 1099

Alvarez, W. C., 276, 2 99, 826, 838

Alzheimer, A., 864, 918

Amatruda, C. S., 603, 613, 621, 650, 664,

666, 672, 686

Amen, E. W., 660, 684

American Council on Education, 154, 162,

166

Ames, L. B., 664, 666, 672, 686

Amsden, G. S., 1134, 1/57

Anastasi, A., 34, 44, 244, 246, 525, 878,

891, 910

Anderson, C., 355, 377

Anderson, E. E., 310, 329, 870, 910

Anderson, G. W., 989, 1028

Anderson, H. II., 340, 377, 684

Anderson, J. E., 222, 247, 678, 684

Anderson, J. P., 656, 684

Anderson, N., 161, 166, 738, 755

Anderson, O. D., 98, 131, 281, 307, 391

392, 396, 397, 407, 408, 410, 411, 584,

610, 834, 860

Anderson, V. V., 811, 819

Andrews, E. S., 200, 205

Andrews, H. L., 1035, 1036, 1037, 1038

1039, 1042, 1044, 1047, 1056, 1058, 1066^

1078, 1087, 1091, 1094

Angyal, A., 43, 44, 70, 131, 890, 896, 910,

991. 1022

Ansbacher, H. L., 149, 167, 185, 205

Anton, G., 780, 789

Appel, K. E., 245, 246, 778, 789, 870, 915,

920, 1094, 1H8, 1134, 1148, 1158

Arakelian, P., 311, 380

Aring, C. D., 699, 610

Aristotle, 270, 98

Armstrong, H. G., 686, 698, 610

Arnheim, R., 43, 44

Arnold-Forster, M., 218, 221, &48

Asch, S. E., 633, 647

Aschaffenburg, G., 999, 10&8

Asenjo, A., 1034, 1087

Ashe, W. F., 600, 617

Asher, E. J., 146, 167

Asher, L., 605, 610

Askanasy, H., 669, 579

Atkinson, J. J., 725, 735

Atwell, C. R., 953, 965, 984

Auer, E. T., 415, 416, 417, 420, 428

Ault, C. C., 608, 617, 618, 884, 885, 910,

921

Avebury, Lord, 1162

Aveling, F., 183, 205, 471, 498

Axelrad, S., 820

Ayer, J. B., 525

B

Baar, J., 74, 131

Babcock, H., 898, 910, 972, 978, 979, 980,

985, 996, 1006, 10* n

"93

1 194

AUTHOR INDEX

Babcock, M. E., 183, 10

Baborka, C. J., 599, 618

Bacon, C., 299

Baer, A., 599, 617

Baer. L. O., 201, 808

Bagby, E., 222, 246

Bagchi, B. K., 1056, 1087

Bailey, P., 779, 789, 865, 010

Baird, J. W., 990, 1022

Baker, A. B., 590, 610

Baker, C. S., Jr., 475. 498

Baker, H. S., 205

Bakes, F. P., 1056, 1087

Bakwin, H., 88, 131, 646

Bakwin, R. M., 88, 131, 646

Balado, M., 1035, 1087

Baldes, E. J., 1050, 1074, 1098, 1103

Baldwin, J. M., 498

Balken, E. R., 236, 237, 238, 246, 249

Bail, R. J., 183, 205, 1022

Bamford, C., 866, 910

Banker, M. H., 688

Barach, A. L., 586, 611, 1146, 1160

Barber, V., 1056, 11 OS

Barcroft, J., 585, 586, 588, 611, 636, 649

Bard, P., 271, 294, 298, 304, 603, 606, 611,

1119, 1158

Bardeen, C. R., 546

Bardsley, R., 1095

Barker, R. G M 125, 131, 314, 316, 329, 379,

387, 444, 464, 682, 689, 693, 712, 1018,

1022

Barnes, G., 898, 910, 1022

Barnes, M. P., 953, 965

Barnett, A., 1087

Barrera, S. E., 956, 966, 1035, 1086, 1099

Barrett, E. B., 1117, 1158

Barrett, W. G., 684

Barren, D. H., 636, 6J,9

Barry, H., 199, 205

Barry, H., Jr., 17, 44, 471, 498

Bartemeier, L. H., 292, 303, 810, 819

Bartlett, F. C, 733

Bartley, S. H., 1037, 1087

Baruch, D. W., 242, 246, 656, 682, 684

Bass, M. J., 475, 479, 498

Bateson, G., 79, 131, 655, 685, 729, 731,

732 733

Bateson, W., 506, 523

Battle, W., 822, 832

Baudouin, A., 1035, 1079, 1087

Baudouin, C., 473, 498, 1111, 1158

Bauer, J., 546

Baxt, J. O., 402, 408, 411

Bayne, T. L., 391, 412, 575, 580

Baynes, H. G., 244, 246

Bayroff, A. G., 420, 428

Bayton, J. A., 345, 350, 351, 378

Beach, F. A., Jr., 583, 603, 611

Beaglehole, E., 126, 131

Beaglehole, P., 126, 131

Bean, R. B., 546

Beble, G. L., 1006, 1028

Beck, A., 866, 910

Beck, H. G., 587, 611

Beck, S. J., 228, 230, 233, 234, 246, 249

Becker, R. F., 588, 6/8

Beckman, R. O., 188, 205

Beerman, H., 288, 289, 302

Beers, C. W., 1128, 1158

Behm, K., 781, 789

Behnsen, G., 1076, 1094

Bell, A., 278, 299

Bell, H. M., 185, 188, 205

Bell, J., 509, 515, 523

Benda, C. E., 554, 555, 568, 571, 578

Bender, I. E., 43, 44

Bender, L., 199, 205, 243, 245, 246, 247,

593, 611, 654, 675, 685, 773, 787, 789,

895, 910, 990, 992, 1002, 1006, 1023,

1148, 1158

Benedek, T., 273, 290, 291, 299, SOS, 608,

611

Benedetti, P., 54 6

Benedict, E., 273, 300

Benedict, R., 106, 132, 719, 720, 721, 722,

733

Benedikt, M., 803, 819

Beneke, F. W., 529, 530, 546

Benjamin, K., 762, 789

Benjamin, J. D., 235, 247

Bennett, A. E., 1079, 1088, 1162

Benson, O. O., Jr., 1098

Benton, A. L., 190, 205, 582, 611

Berger, E., 245, 247

Berger, H., 942, 964, 1033, 1034, 1035,

1036, 1038, 1040, 1041, 1047, 1050, 1052,

1053, 1054, 1056, 1057, 1058, 1062, 1064,

1065, 1068, 1069, 1072, 1073, 1076, 1078,

1079, 1085, 1088

Bergman, G. von, 276, 299

Beringer, K., 891, 896, 910

Beritoff, J. S., 459, 464

Berkman, M., 685

Berman, L., 9, 44

Bernard, C., 601, 611

Berne, E. V., 167

Bernfeld, S., 6V,9, 712

Bernhard, C. G., 1053, 1089

Bernhardt, K. S., 420, 426, 428

Bernheim, H., 469, 470, 472, 473, 474, 478,

498, 888, 910

Bernreuter, R. G., 186, 189, 204, 205

Bernstein, E., 200, 205

Bertrand, L, 1034, 1080, 1088, 1089, 1093

Berze, J., 901, 910

Betts, E. A., 784, 789

Bevan-Lewis, W., 993, 1023

Bianchi, L., 567, 578

Biber, B., 677, 679, 685

Biel, W. C., 596, 598, 611, 618

Biesheuvel, S., 182, 205

Billings, E., 885, 889, 896, 910, 1177, 1182,

1190

Billingslea, F. Y., 424, 426, 428

Bills, A. G., 586, 611

Binet, A., 183, 205, 472, 478, 485, 498

Bingham, W. E., 144, 167

Bini, L., 1152, 1158

Bird, C., 1023

Bird, G. E., 200, 205

Bishop, G. H., 1035, 1037, 1087, 1088, 1089

Bissell, J. B., 781, 789

Bize, P. R., 682, 685

Bjerre, P., 906, 910

Bjornstrom, F., 472, 485, 498

Blackberg, S. N., 547

Blair, G. M., 199, 205

Blake, H., 1060, 1068, 1076, 1089

Blanchard, E., 870, 916

(Volume I pages 1 to 618)

AUTHOR INDEX

1195

Blanchard, P., 222, 247, 687, 712, 766, 792,

1162

Blatz, W. D., 605, 611, 685

Blatz, W. E., 775, 789

Blaurock, M., 281, 301

Bleuler, E., 16, 44, 217, 247, 546, 868, 869,

889, 891, 897, 901, 906, 907, 908, 910,

911

Blitzsten, D., 1162

Block, H., 533, 547

Bloomfield, R., 597, 598, 612

Bloor, C, 9, 44

Bios, P., 1168, 1182, 1190

Bluemel, C. S., 783, 789

Blumer, H., 755

Boas, F., 716, 717, 733

Boelter, M. D., 598, 614

Bogardus, E. S., 191, 205

Boldrey, E., 966

Bolles, M. M., 902, 911, 987, 1013, 1015,

1016, 1019, 1023, 1061, 1102

Bond, E. D., 275, 299, 594, 611, 778, 789,

886, 911, 1151, 1155, 1158

Bone, H., 1162

Bonkalo, A., 1066, 1067, 1068, 1093

Bonner, C, 869, 870, 911

Boring, E. G., 472, 498, 1004, 1023

Bosquet, S., 1130, 1158

Bossard, J. H. S., 755

Bosselman, B., 519, 523

Bostroem, A., 571, 578

Bott, E. A., 775, 789

Boudin, M., 515, 523

Boudreau, E. N., 590, 611

Bourne, G., 285, 301

Bousfield, W. A., 205

Bowden, A. O., 5, 44

Bowen, B. D., 590, 615

Bowers, A. M., 326, 330, 1015, 1026

Bowers, P. E., 819

Bowers, R. V., 755

Bowman, K. M., 881, 911, 991, 1023, 1051,

1100, 1146, 1153, 1158

Braceland, F. J., 1123, 1151, 1155, 1158,

1161

Bradley, C., 561, 580, 681, 685, 761, 770,

787, 789, 790, 936, 1095, 1097, 1158

Bradshaw, F. F., 151, 152, 167

Bragman, L. J., 764, 789

Braid, J., 474, 478, 491, 498

Brain, R., 514, 523

Brainard, P. P., 194, 205

Bramwell, J. M., 469, 470, 472, 473, 474,

476, 478, 485, 486, 491, 498

Brander, T., 685

Brandt, H. F., 340, 377

Brandt, W., 546

Branham, V. C., 953, 964

Braun, F., 42, 44

Braun, R., 599, 617

Braune, 595, 611

Bremer, F., 1034, 1037, 1089

Brenman, M., 488, 498

Breuer, J., 216, 247, 622, 649, 888, 911,

1111, 1135, 1158, 1159

Brew, M., 869, 911

Brewer, J. M., 165, 167

Brickner, R. M., 569, 579, 958, 964, 977,

1023

Bridge, E. M., 953, 964

Brill, A., 906, 911

Brill, N. Q., 1034, 1053, 1064, 1085, 1089

Brintnall, A. K., 494, 499

Bristol, C, 165, 167

Brock, J., 629, 637, 643, 649

Brodmann, K., 566, 579

Brody, E. B., 605, 611

Brody, M. B., 972, 985, 988, 1023

Brogan, W., 143, 167

Brogden, H. E., 39, 44, 200, 205

Bromberg, W., 270, 298, 799, 805, 808, 809

811, 813, 819

Bronner, A., 326, 330, 703, 712, 798, 811,

813, 814, 820, 1015, 1026

Bronstein, I. P., 603, 604, 605, 611, 612,

615, 616

Brooks, C. H., 473, 498

Brooks, J. J., 200, 205

Brouha, L., 597, 598, 612, 614

Brousseau, K., 778, 789

Brown, A. G., 590, 611

Brown, A. W., 594, 603, 604, 605, 611, 612,

614, 6/5, 616

Brown, F., 186, 205

Brown, F. W., 783, 789

Brown, G. D., 685

Brown, J. F., 64, 66, 131, 132, 853, 860,

892, 906, 908, 911, 1023

Brown, J. S., 318, 329, 434, 437, 452, 454,

464, 465

Brown, M., 952, 957, 966

Brown, S., 765, 789

Brown, W., 183, 205, 279, 299, 472, 473,

498, 1111, 1113, 1158

Brown, W. T., 1085, 1089

Browne, C. E., 652, 687

Bruch, H., 274, 299, 597, 611, 682, 685

Brunswick, R., 906, 911

Brush, A. L., 608, 611

Brush, L. A., 273, 299

Bryan, E., 894, 911

Bryan, R., 155, 156, 167

Bryant, J., 546

Bucy, P. C., 565, 575, 580, 1076, 1079,

1089

Bugelski, R., 310, 329

Biihler, C., 621, 649, 654, 685

Bull, H. B., 576, 580

Bull, H. D., 608, 610

Bumke, O., 896, 911

Bunch, M. E., 460, 464

Burchard, E. M. L,, 533, 646, 863, $11,

982, 1024

Burdick, E. M., 199, 205

Burgemeister, B. B., 194, SOS

Burgess, E. W., 741, 766, 766

Burgum, M., 661, 685

Burke, R. S., 200, 07

Burks, B. S., 35, 44. 201, 206. 611, 512,

523, 662, 684, 685, 687

Burling, T., 1182, 1190

Burlingame, C. C., 608, 618, 981, 10W,

1164, 1168

Burlingame, L. L., 526

Burnham, R. W., 606, 612

Euros, O, K., 204, 206

Burt, C, 30, 31, 32, 33, 34, 35, 37, 38, 43,

44, 146, 168, 685

Burtt, H. E., 142, 150, 152, 167, 183, 198,

206

(Volume // pages 619 to

1196

AUTHOR INDEX

Buscaino, V., 864, 911

Busemann, A., 762, 789

Butler, B. E., 600, 616

Butterfield, O. M., 1162

Buytenijk, F. J. J., 1035, 1087

Bychowski, G., 891, 892, 902, 911, 1019,

1023

Byers, R. K., 1034, 1089

Cabot, P. S. deQ., 533, 546, 685, 863, 911

Cabot, R. C., 1172, 1190

Cadbury, W., 281, SOI

Cady, B. C., 1162

Cady, V. M., 1162

Cahane, M., 606, 612

Cahane, T., 606, 612

Caldwell, J. M., Jr., 810, 819, 869, 911

Caldwell, O. W., 198, 206

Call, A. P., 1119, 1120, 1158

Cameron, D. E., 867, 895, 911, 1008, 1023,

1082, 1093, 1094

Cameron, E. S., 870, 912

Cameron, H. C., 775, 789, 1162

Cameron, M. A., 168

Cameron, N., 314, 329, 862, 867, 868, 870,

872, 874, 886, 890, 891, 899, 900, 902,

903, 906, 911, 912, 991, 1015, 1016, 1017,

1018, 1019, 1023

Cameron, W. J., 685

Campbell, A. A., 775, 789

Campbell, C., 888, 890, 896, 912

Campbell, C. M., 293, 304

Campbell, E. H., 685

Campbell, J. K., 533, 546

Campbell, M. C., 1050, 1083, 1091

Campion, G. S., 572, 579

Cannon, W. B., 75, 117, 132, 271, 281, 294,

298, 301, 304, 400, ^11, 601, 606, 612,

103X 1100

Cantril, H, 42, 43, 44

Canway, C. B., 168

Capps, H. M., 982, 1023

Caprile, A. M. A., 1034, 1089

Carlson, A. J., 600, 612

Carlson, E. R., 779, 789

Carlson, W. A., 1098

Carlson, W. S., 42, 44

Carmichael, H. T., 290, 303, 866, 912

Carmichael, L., 4, 48, 414, 428, 1034, 109*

Carpenter, J., 685

Carpenter, N., 755

Carr, H. A., 606, 612

Carrillo, R., 1034, 1089

Cartwright, D., 455, 464

Casamajor, L., 1072, 1089

Case, H. W., 494, 499

Case, T. J,, 1076, 1079, 1089

Cash, P. T., 1088

Cason, H., 187, 199, 206, 222, 24?

Caster, J. E., 475, 498

Castner, B. M., 664, 666, 672, 686

Cattell, J. McK., 151, 152, 167

Cattell, R. B., 39, 44, 76, 132, 182, 185,

206

Caughey, J., 284, 285, 501

Cavan, R. S., 161, 167, 738, 739, 740, 747,

755

Cerletti, V., 1152, 1158

Chambers, F. T., 1147, 1161

Champney, H., 654, 685

Chandler, C. A., 278, 300

Chapin, F. S., 199, 206

Chapman, D. W., 341, 377

Chappie, E. D., 732, 733

Chave, E. J., 685

Cheney, C., 863, 869, 870, 871, 883, 886,

892, 907, 909, 912, 915, 1125, 1160

Chick, H., 421, 425, 427, 428

Child, C. M., 269, 298

Child, J. L., 204, 206

Chobot, R., 595, 612, 682, 685, 770, 789

Chodoff, P., 1099

Chornyak, J., 587, 618

Christoffel, H., 293, 30.)

Chweitzer, A., 1066, 1089

Ciocco, A., 5^6

Cisler, L. E., 594, 611, 614

Clardy, E. R., 1083, 1089

Clark, E. L., 144, 167

Clark, L., 1162

Clark, L. P., 771, 789, 954, 956, 957, 965

Clark, W. H., 182, 206

Clark, W. W., 170, 212

Clarke, E. K., 762, 789

Cleckley, H. M., 599, 612, 617, 810, 819

Clegg, J., 866, 912

Cleveland, S. E., 1012, 1013, 1015, 1023

Clifford, M., 273, 300

Clothier, F., 685

Clothier, R., 151, 168

Cobb, I. B., 9, 44

Cobb, S., 278, 286, 288, 292, 300, 302, 303,

552, 555, 568, 575, 579, 588, 592, 612,

613, 860, 938, 966, 1072, 1078, 1089,

1101

Codet, H., 607, 612

Cofer, C. N., 1102

Coghill, G. E., 41, 44, 269, 298, 395, 411,

551, 579, 622, 629, 649

Cohen, D. W., 765, 789

Cohen, L., 587, 612

Cohen, L. H., 1002, 1023, 1082, 1100

Cohn, R., 1064, 1066, 1089

Colby, M. B., 599, 612

Cole, L., 692, 703, 712

Cole, L. W., 983, 984, 1029

Collias, N. E., 607, 608, 610

Collier, W. A., 548

Collins, A. L., 953, 965

Conel, J. L., 628, 649

Conkey, R., 582, 989, 1012

Conklin, E. S., 195, 206

Conn, J., 864, 869, 912

Conn, J. C. M., 953, 955, 965

Conn, J. H., 122, 132, 240, 247, 685, 773,

788, 789, 1148, 1158

Connolly, C J., 546

Conrad, H. S., 978, 987, 1027

Consolagio, F., 597, 598, 612

Constable, K., 1089

Constantinesco, G., 1099

Cook, L. C., 1086, 1089

Cook, S. W., 413, 428

Cooley, T. B., 599, 612

Coon, G. P., 1154, 1158

Cooper, G., 281, 301

Coover, J. E., 326, 329

(Volume I pages 1 to 618)

AUTHOR INDEX

1197

Copeland, H. A., 37, 40, 44

Coriat, I. H., 273, 299, 895, 912, 1002,

1023

Cornell, E. L., 974, 975, 1023

Cosack, H., 763, 789

Coster, G., 1162

Cottenot, P., 1034, 1089

Cotterman, C. W., 508, 511, 523

Cotton, H. A., 865, 897, 912, 1110, 1124,

1158, 1159

Couch, F. H., 998, 1023

Coue, E., 1112, 1113, 1159

Courts, F. A., 460, 464

Courville, C. B., 587, 612

Cowan, E. A., 685

Cowdery, K. M., 193, 206

Cowell, J., 244, 246, 250

Cowley, W. H., 41, 44

Craig, W. M., 1103

Crane, A. L., 178, 206

Creak, M., 687

Crile, G., 604, 612

Cronin, H. J., 957, 965

Crosland, H., 181, 206, 226, 247

Crothers, T. D., 8/9

Crowley, M. E., 418, 430

Cruickshank, R. M., 1047, 1054, 1056,

1057, 1089, 1094

Crutcher, R., 182, 206

Cucchi, A., 1034, 1089

Culler, E., 53, 66, 84, 132

Culotta, C. S., 603, 613

Cunningham, B., 605, 615

Cupcea, S., 991, 1023, 1029

Curran, F. J,, 243, 247, 819, 1008, 1023

Currie, J. P., 996, 998, 1032

Curtis, J. N., 983, 1023

Curtis, Q. F., 4*2

Gushing, H. M., 182, 06, 277, 299

Gushing, K., 957, 965

Cutts, K. K., 1066, 1067, 1080, 1085, 1089,

1097

Czarski, T. J., 1098

Dabelstein, D. H., 201, 207

Dahlberg, G., 510, 523

Dahms, H., 1023

Dallear, A. H., 1002, 1029

Dalsgaard-Niclsen, T., 1035, 1090

Dalton, J. W., 583, 584, 614

Dandy, W. E., 606, 612

Danforth, C. H., 610

Daniel, R. P., 200, 206

Daniels, G. E., 290, 303

Daniels, G. F., 276, 279, 299

Danielson, F. H., 518, 523

Darley, J. G., 162, 169, 187, 209

Darling, R. C., 597, 598, 612, 614

Darling, R. P., 184, 206, 685

Darrah, L., 899, 912

Darrow, C. W., 39, 44, 281, 301, 895, 912,

1059, 1090

Darwin, C., 506, 523

Davenport, C. B., 517, 518, 523, 546, 740,

756

David, M., 569, 579

Davidoff, E., 607, 612, 1146, 1159

Davidoff, L. M., 958, 965

Davidson, H. H., 234, 247

Davidson, M., 898, 912, 981, 982, 1024

Davie, M. R., 755

Davies, A., 898, 912

Davies, D. T., 276, 299

Davies, E., 779, 790

Davis, A., 61, 66, 78, 122, 132

Davis, C M., 132, 602, 612

Davis, G. B., 412

Davis, H., 942, 943, 945, 965, 966, 1034,

1035, 1039, 1044, 1045, 1047, 1048,

1050, 1057, 1063, 1064, 1068, 1083,

1090, 1091, 1092, 1100

Davis, K. B., 685, 785, 790

Davis, L. W., 471, 498

Davis, M., 440, 465

Davis, P. A., 945, 965, 1034, 1039, 1045,

1047, 1050, 1056, 1062, 1064, 1067,

1083, 1084, 1086, 1090, 1100

Dawson, S., 953, 955, 965

Dayton, N. A., 755, 872, 907, 909,

912

Dearborn, G: V. N., 1024

DeBruyn, J. W., 1002, 1094

de Cillis, O. E., 595, 616, 689

Decroly, O., 183, 206

Dee, W. L. J., 755

Dejerine, J., 1115, 1110, 1159

DeKok, W., 1162

Delay, J., 1088, 1093

D'Elseaux, F. C., 593, 612

Dembo, G., 125, 131, 314, 316, 329, 333,

356, 377, 379, 387, 1018, 1022

Dempsey, E. W., 1037, 1090

de Natale, F., 869, 918

Dennett, M. W., 1162

Dennis, W., 102, 106, 122, 132, 640, 649,

655, 659, 686, 733

De Sanctis, R. M., 595, 612

De Sanctis, S., 767, 770, 789, 790

De Schweinitz, K., 1162

Despert, J. L., 238, 243, 247, 660, 681, 686,

763, 773, 790, 900, 903, 912, 1015, 1024,

1148, 1159

Dession, G. H., 930, 936

Dessoir, M., 473, 498, 499

Detweiler, S. R., 622, 649

Deutsch, A., 870, 879, 900, 912

Deutsch, F., 274, 288, 300, 302

Deutsch, H., 263, 267

Devereux, G., 108, 115, 132

Dewan, J. G., 1098

Dewar, H., 198, 206

Dice, L. R., 415, 421, 428

Dickson, W. J., 57, 68

Diefendorf, A. R., 779, 790, 993, 998, 1024

Diethelm, O., 869, 870, 877, 881, 882, 884,

885, 889, 895, 900, 908, 912, 956, 965.

1110, 1112, 1126, 1159

Di Giovanni, A., 528, 546

Dockart, M. B., 1006, 1030

Dodge, R., 998, 1024

Doisy, E. A., 610

Doll, E. A., 200, 206, 518, 522, 523, 686,

779, 790

Dollard, J., 52, 53, 61, 64, 66, 68, 78, 79,

80, 81, 84, 103, 107, 110, 113, 118, 122,

132, 134, 161, 167, 315, 319, 329, 383,

(Volume // -pages 619 to 1191)

1198

587, 434, 439, 441, 450, 65, 696, 712,

719, 755, 755

Domarus, E. von, 894, 901, 912

Donaldson, H. H., 415, 420, 428

Donnison, C. P., 281, SOI

Doob, L. W., 64, 66, 315, 316, 317, 319,

529, 383, 587

Dooley, L., 869, 912

Doolittlc, G. J., 953, 955, 965

Dorcus, R. M., 473, 474, 494, 498, 499

Dorsey, J. M., 995, 1021,, 1031

Dowd, C. E., 45

Downey, J. E., 9, 45, 180, 181, 206, 212

Drahms, A., 803, 819

Drake, R. M., 198, 206

Draper, G., 276, 284, 292, 299, 304, 535,

546, 963, 966

Drewry, P., 870, 912

Droba, D. D., 192, 206

Droese, W., 599, 612

Dubin, R., 199, 206

Dubin, S. S-, 241, 243, 247

Dublin, L. L, 739, 755

Du Bois, C, 115, 132, 655, 686, 755

Dubois, P. H., 315, 329, 895, 916, 987,

1024, 1113, 1115, 1116, 1/59

Dudycha, G. J., 153, 167, 200, 206

Duffy, E. A., 197, 206

Dugdale, R. L., 518, 525, 803, 819

Duguid, K., 286, 302

Dunbar, H. F., 269, 270, 271, 281, 285,

286, 288, 289, 290, 298, 501, 302, 303,

535, 546, 860, 867, 913

Dunham, H. W., 740, 743, 746, 747, 749,

755, 978, 1024

Dunlap, C, 864, 915

Durea, M. A., 686

Durkheim, E., 736, 755

Durup, G., 1056, 1090

Dusser de Barenne, J. G., 941, 965, 1037,

1090

Dworkin, E., 402, 408, 411

Dworkin, S., 400, 402, 408, 411

Dynes, J. B., 1076, 1091

Dysinger, D. W., 995, 1024

Eastman, N. J., 587, 612

Ebaugh, F. G., 227, 235, 247, 431, 465,

833, 860, 883, 888, 915, 920, 922, 927,

957, 1150, 1161

Eccles, A. K., 604, 615

Echlin, F. A., 1091

Economo, C. von, 551, 579

Edman, I., 1132, 1159

Efron, D., 57, 66

Egan, J. P., 1056, 1102

Egana, E., 597, 598, 612, 614

Ehrlich, W., 4, 45

Eisenberg, P., 42, 43, 45, 184, 206, 685

Eliet, J., 279, 500

Elkin, J., 182, 209

Eller, J. J., 583, 612

Ellingson, M., 163, 167

Elliott, G. L., 712, 1162

Ellis, H., 532, 546, 1162

Ellis, W. D., 1024

Ellson, D. G., 311, 550

AUTHOR INDEX

El Sadr, M. M., 421, 425, 428

Elsom, K. O., 597, 615

Elvidge, A., 1095

Elvidge, H., 864, 915

Elwood, M. L, 983, 1024

Engel, G. L., 1080, 1091, 1098

English, H. B., 663, 686

Enke, W., 533, 546

Enzer, N., 599, 607, 617

Epstein, S. H., 987, 1024

Erickson, E. M., 477, 499

Erickson, M. H., 226, 248, 323, 550, 470,

477, 478, 480, 482, 483, 484, 487, 488,

490, 499, 500, 890, 914

Erickson, T. C., 566, 580

Erikson, E. H., 87, 103, 118, 152, 239,

240, 241, 242, 247, 584, 616, 652, 653,

655, 659, 660, 665, 686, 733 t 734 (See

Homburger, E. H.)

Ernst, K., 519, 523

Escalona, S. K., 356, 357, 362, 375-6,

577, 1003, 1024

Esdaile, J., 473, 474, 491, 499

Estabrook, A. H., 518, 525

Estabrooks, G. H., 467, 471, 499

Estes, S. G., 42, 45

Estes, W. K., 52, 67

Evans, C., 186, 206

Evans, J. N., 586, 615

Evans, J. T., 413, 428

Everall, E. E., 310, 550

Ewing, A. W. G., 784, 790

Exner, M. J., 785, 790

Eyman, E., 870, 920

Eymieu, A., 1117, 1159

Eyrich, M., 955, 965

Fairlie, C. W., 310, 550

Fales, E., 354, 577

Farber, M., 863, 915

Faris, R. E. L., 739, 740, 746, 747, 749,

755, 978, 1024

Farnsworth, P. R., 200, 206, 686

Farquharson, H., 274, 299

Farr, C., 870, 884, 915, 920, 1158

Farrar, C., 875, 879, 884, 915

Farris, E. J., 419, 423, 428

Faulkner, W. B., 275, 299

Fauquier, W., 181, 206, 686

Fay, P. J., 43, 45

Fazekas, J. F., 588, 599, 615, 614, 1093

Feder, D. D., 201, 206

Feigenbaum, J., 546

Feindel, E., 781, 791

Feldstein, M. H., 159, 168

Fenichel, O. f 99, 109, 120, 131, 152, 463,

464, 853, 860, 869, 878, 915, 991, 995,

1024, 1137

Fenton, 187, 215

Fere, C., 472, 478, 485, 498

Ferenczi, S., 275, 299, 504, 474, 492, 499,

625, 649

Ferguson, W. G., 591, 616, 863, 919

Fernald, G. G., 174, 207, 825, 852

Fernald, M. R., 604, 615

Fernald, W. E., 800, 819, 824, 852

Ferrero, Mme. 802, 819

(Volume 1 pages 1 to 618)

AUTHOR INDEX

"99

Ferris, E. B., Jr., 599, 610

Fessard, A., 1034, 1056, 1090, 1091

Festinger, L., 338, 342, 344, 345, 353,

356, 377

Fetterman, J., 953, 965

Field, M., 686

Fields, P. E., 414, 428

Filter, R. O. 7, 45

Finan, J. L., 309, 330

Finch, G., 84, 132

Finesinger, G. L., 575, 579

Finesinger, J. E., 575, 579, 584, 612

Finger, F. W., 414, 416, 418, 419, 420,

422, 423, 424, 1,2$, 462, 464

Fink, A. E., 800, 802, 803, 819

Finley, K. H., 1050, 1076, 1079, 1083,

1085, 1091, 1101, 1102

Fischer, M. H., 1034, 1091

Fischgold, H., 1035, 1087

Fisher, R. A., 506, 509, 511, 512, 523

Fisher, V. E., 199, 213, 480, .$99

Fite, M. D., 668, 671, 674, 686, 687

Fitzpatrick, C. P., 1095

Flanagan, D., 322, 330

Flanagan, J. C., 39, 45, 204, 207

Fleck, U., 956, 965

Fleming, G., 871, 880, 886, 913

Fleming, G. W. T. H., 1086, 1091

Fleming, J., 246, 247

Fleming, R., 1146, 1147, 1159

Fletcher, F. M., 310, 330

Fletcher, P., 1120, 1161

Fliigel, J. C., 130, 132, 626, 649, 686

Foerster, O., 557, 571, 579, 1036, 1038,

1076, 1091

Foley, J. P., 57, 67, 244, 246, 878, 891,

910

Foltz, E. E., 599, 612

Foltz, L. M., 1161

Fonner, D., 953, 966

Forbes, A., 1099

Forbes, T. W., 315, 329, 895, 9/6, 1002,

1024, 1056, 1091, 1102

Forbes, W. H., 597, 598, 614

Forel, A., 473, 478, 486, /,98, 499

Forlano, G., 199, 207

Forman, J., 770, 790

Fortes, M., 733

Fortune, R. F., 733

Fosberg, I. A., 232, 247

Foster, J. C, 222, 247 t 1006, 1008, 1024

Foster, J. H., 281, 301

Foster, R., 605, 612

Foster, S., 686, 782, 790

Fothergill, L. D., 559, 579

Fourier, C., 24, 45

Fowler, M. G., 688

Fowler, O. D., 1066, 1067, 1091

Fox, G. F., 478, 501

Fox, H., 869, 913

Fox, J. C, 998, 1023, 1024

Fox, J. T., 953, 965

Foxe, A. N., 809, 818, 819

Frank, J. D., 199, 207, 333, 335, 339,

344, 345, 347, 351, 377

Frank, L. K., 91, 93, 129, 132, 215, 2J7,

655, 686, 73S

Franke, L. J., 1091

Franks, R., 884, 913

Franz, J. G., 243, 247

Franz, S. I., 480, 499, 567, 579, 990, 993,

995, 997, 998, 999, 1024

Fraser, F. R., 592, 613

Eraser, R., 588, 6*2

Frazier, E. F., 739, 755

Frederiksen, N., 318, 330

Freeman, F. N., 525

Freeman, G. L., 1057, 1091

Freeman, H., 1002, 1024, 1066, 1067,

1100

Freeman, W., 546, 551, 570, 571, 579,

864, 865, 868, 913, 920, 958, 965, 977,

1024, 1091, 1125, 1146, 1152, 1153, 1159,

1161

Fremont-Smith, F., 592, 612

Frenay, A. D., 739, 755

French, T. M., 64, 67, 132, 265, 267, 270,

286, 288, 289, 290, 295, 298, 302, 304,

1018, 1024

Frenkel-Brunswik, E., 321, 330

Freud, A,, 116, 126, 127, 129, 132, 217, 239,

247, 267, 627, 644, 649, 652, 686, 698,

712, 768, 772, 790, 1141, 1149, 1159,

1162

Freud, S., 79, 96, 112, 113, 114, 120,

123-4, 132, 214, 216, 217, 218, 219, 220,

247, 262, 264, 267, 270, 272, 274, 278,

280, 290, 293, 294, 295, 298, 299, 303,

304, 307, 315, 319, 320, 321, 324, 325,

326, 330, 385, 387, 431, 464, 492, 499,

622, 623, 624, 625, 626, 627, 630, 643,

649, 653, 686, 725, 733, 764, 768, 790,

853, 854, 860, 869, 874, 888, 889, 891,

900, 901, 905, 907, 908, 911, 913, 999,

1024, H09, 1111, 1135, 1136, 1139, 1140,

1158, 1159

Frey, O. C, 183, 206

Frey, T., 1091

Freyd, M., 150, 167, 193, 207

Friedlander, J. W., 471, 499

Friedman, E., 1152, 1160

Friedman, H., 1095

Fries, M. E., 87, 92, 132, 133, 653, 664,

671, 686, 1175, 1177, 1190

Fritsch, G., 941, 965

Fromm, E., 653, 659, 686, 733

Fromm-Reichmann, F., 64, 67, 292, 303,

659, 681, 686

Frostig, J., 891, 894, 913, 1093

Fry, F. D., 982, 1024

Fryer, D., 194, 195, 207

Fuller, R. G., 525, 863, 918

Fulton, J. F., 277, 300, 551, 555, 565, 567,

579

Furfey, P. H., 200, 207

Gagel, O., 557, 571, 570

Gagne, R. M., 995, 1025

Gahagan, L., 953, 955, 966

Galambos, R., 420, 429

Gall, F. J., 29, 45

Gallagher, J. R., 959, 965

Gallup, G., 59, 67

Galton, F., 12, 45, 223, 227, 2*7, 506, 510,

523, 999, 1024

Gannon, J. T., 200, 207

(Volume II pages 619 to 1191)

1200

AUTHOR INDEX

Gantt, W. H., 271, 298, 392, 400, 403, 404,

406, 407, 408, 409, 410, 412, 1006, 1008,

1024

Garceau, E. L., 1044, 1091

Gardner, G. E., 327, 330, 900, 913, 1025

Gardner, J. W., 336, 341, 347, 349, 351,

352, 577

Garnett, J. C M. f 39, 45

Garretson, O. K., 194, 207

Garrett, H. E., 140, 167, 546

Garrison, F. H., 870, 913, 1107, 1159

Garrison, K. C, 194, 207, 694, 712

Garrod, A. E., 506, 524

Garvey, C. R., 533, 546

Gascon, A., 1034, 1089

Gates, A. L, 784, 790

Gates, R. R., 506, 508, 524

Gatewood, L. C., 897, 903, 913, 985, 1004,

1015, 1025

Gaylor, J., 895, 913

Geblewicz, E., 1089

Gelb, A., 902, 913, 990, 991, 992, 1010,

1025

Gellhorn, E., 117, 133, 588, 590, 592, 613

Gemelli, A., 1040, 1058, 1091

Gentry, C. G., 194, 207

Gerard, M. W., 293, 304, 687

Gerard, R. D., 1035, 1037, 1097

Gerard, R. W., 1035, 1037, 1060, 1065,

1068, 1089, 1091

Gerlach, M., 686

Gesell, A., 603, 613, 621, 632, 650, 664,

666, 672, 686

Gibbs, C., 863, 913

Gibbs, E. L., 586, 590, 614, 941, 942, 943,

944, 945, 966, 1033, 1034, 1039, 1042,

1043, 1056, 1063, 1064, 1069, 1071, 1091,

1092, 1097, 1099, 1102

Gibbs, F. A., 586, 590, 614, 941, 942, 943,

944, 945, 959, 965, 966, 1033, 1034, 1035,

1039, 1041, 1042, 1043, 1057, 1062, 1063,

1064, 1065, 1066, 1067, 1069, 1070, 1071,

1072, 1073, 1074, 1076, 1078, 1082, 1083,

1090, 1091, 1092, 1093, 1097, 1099, 1102,

1103

Gibson, E. J., 455, 464

Gieslin, L. E., 599, 612

Gilbert, J. G., 979, 980, 988, 1025

Gildea, E. F., 546, 588, 613

Gilkinson, H., 200, 207

Gill, S. E., 687

Gillespie, R. D., 770, 790, 870, 883, 886,

892, 905, 907, 914, 922, 927, 936, 1145,

1159

Gilliland, A. R., 186, 200, 207

Gillin, J., 739, 755

Gilman, A., 457, 464

Girden, E., 459, 464

Gist, N. P., 737, 755

Gitelson, M., 243, 247, 687

Glaser, E. A., 196, 197, 207

Glaser, M. A., 1078, 1092

Glaser, N. M., 414, 415, 420, 421, 422,

424, 425, 426, 429

Glaze, J. A., 596, 613

Gliebe, P. A., 583, 584, 592, 614

Glover, E., 834, 860, 874, 878, 914

Glueck, B. G., 806, 819

Glueck, E. T., 702, 712, 1184, 1185,

1190

Glueck, S., 702, 712, 811, 819, 1184, 1185,

1190

Godbeer, E., 446, 464

Goddard, H. H., 479, 499, 506, 518, 524,

804, 806, 819

Godlowski, W., 1034, 1092

Goldensohn, L. N., 242, 243, 250, 1089,

1092

Goldie, E. A. G., 585, 586, 615

Goldman, G., 1056, 1092

Goldman, R., 978, 981, 988, 1006, 1050

Goldsmith, H., 1146, 1159

Goldstein, H., 867, 870, 917

Goldstein, J., 162, 167

Goldstein, K., 386, 387, 551, 557, 562, 566,

579, 653, 687, 891, 892, 902, 903, 911,

914, 989, 990, 991, 992, 1009, 1010,

1011, 1012, 1013, 1016, 1019, 1023, 1025

Goldthwait, J. E., 547

Golla, F., 1072, 1075, 1091, 1092

Golse, J., 1035, 1092

Goodenough, F. L., 42, 45, 181, 207, 775,

782, 790

Goodhart, R., 1146, 1158

Goodman, L., 457, 464

Goodman, S. E., 688

Goodstone, G. L., 607, 612

Goodwin, C. W., 1044, 1093

Goodwin, J. E., 1035, 1093, 1094, 1098

Gordon, A., 1002, 1005, 1025

Gordon, R. G., 594, 613

Gorer, G., 96, 133, 734

Goring, C, 518, 524, 532, 547

Gottke, L., 957, 966

Gottlieb, B., 870, 914

Gottlieb, J., 882, 914, 975, 977, 1028

Gottlober, A. B., 1047, 1048, 1050, 109S,

1102

Gould, J., 420, 429

Gould, R., 337, 342, 343, 344, 347, 351,

354, 378

Cowers, W. R., 952, 953, 966

Gozzano, M., 1034, 1093

Grabfield, G. P., 895, 914, 990, 1025

Graf-Best, A, M., 290, 302

Graham, C. H., 995, 1025

Graham, E. A., 589, 613

Graham, S., 1092

Graham, V. T., 987, 1025

Granet, E., 275, 300

Grant, F., 865, 920

Grass, A. M., 1041, 1045, 1093

Graves, W. W., 547

Gray, E., 146, 167

Graybill, A., 597, 598, 612, 614

Greenacre, P., 626, 650, 687

Greenberg, D. M., 598, 614

Greene, E. B., 152, 167

Greenspan, I., 198, 210

Greer, I. M., 770, 792

Gregorius, J., 965

Greig, A. B., 687

Greulich, W. W., 547

Griesinger, W., 905, 914

Griffin, J. D. M., 985, 989, 1028

Griffith, P. E., 1102

Griffiths, G. M., 110S

Griffiths, R., 594, 613

Griffiths, W. J., Jr., 415, 420, 421, 426,

428

(Volume I pages 1 to 618)

AUTHOR INDEX

1201

Grindley, G. C, 310, 330

Grings, W. W., 1025

Grinker, R. R., 295, $04, 622, 636, 650,

1035, 1043, 1082, 1093, 1097, 1101

Gross, C., 763, 792

Gross, H., 797, 819

Gross, O., 17, 45, 868, 914

Gruhlc, H., 869, 890, 891, 896, 898, 901,

910, 914

Grunbaum, A. M., 221, 247

Grtinthal, E., 568, 571, 579

Gruttner, R., 1066, 1067, 1068, 109S

Guilford, J. P., 32, 34, 39, 45, 186, 207,

991, 1000, 1025, 1026

Guilford, R. B., 39, 45

Guillain, G., 1080, 1093

Guillain, J., 1088, 1093

Guirdham, A., 233, 248

Gull, W., 274, 300

Gulliksen, H., 452, 404

Gundlach, R. H., 533, 547

Gunther, L., 286, 301

Gunwardene, 281, 301

Gutheil, E. A., 221, 248, 292, 303, 809, 819

Guthrie, E. E., 431, 464, 465

Guthrie, E. R., 41, 45, 49, 50, 51, 53, 58,

64, 67, 496, J99

Guthrie, L. J., 786, 790

Gutteridge, M. V., 687

Guttman, E., 687

H

Hackel, W., 547

Hadfield, J. A., 474, 499

Hadidian, Z., 1093

Hadley, J. M., 1057, 1093, 1095

Hadlich, H., 891, 914, 1015, 1025

Hagman, R. R., 782, 790

Haigis, E., 238, 248

Haines, T. H., 806, 819

Halbert, L. A., 737, 755

Halbron, P., 1079, 1087

Halbwachs, M., 739, 747, 755

Haldane, J. B. S., 515, 521, 522, 523, 524,

525, 585, 586, 592, 61,5

Hall, C. S., 414, 416, 417, 419, 420, 421,

426, 428, 429, 687

Hall, G. E., 1035, 1095, 1094

Hall, G. S., 652, 687, 691, 692, 712, 801,

819

Hall, M. B., 682, 687

Hall, M. E., 1056, 1102

Halperin, M. H., 586, 615

Halpern, F., 987, 1031

Halpern, I. W., 755

Halstead, W. C, 977, 1012, 1013, 1025

Halverson, H. M., 640, 650

Hambly, W., 734

Hamil, B. M., 599, 612

Hamilton, A. McL., 820

Hamilton, G. V., 384, 387, 999, 1024

Hamilton, J. A., 310, 330, 591, 613

Hamilton, J. B., 607, 615

Hamilton, J. R., 421, 428

Handclsman, J., 588, 613

Hanfmann, E., 891, 892, 902, 903, 914,

P15, 1012, 1013, 1014, 1015, 1016, 1017,

1025, 1026

Hanken, A. H., 1190

Hankins, D., 700, 712

Harbinson, M. R., 899, 914, 981, 1026

Hardcastle, D. H., 286, 302

Hare, F., 1159

Hargreaves, H. L., 183, 205, 471, 498

Harlow, H., 870, 912

Harms, E., 245, 248, 1148, 1159

Harper, H., 192, 207

Harriman, P. L., 684

Harrington, M., 1179, 1191

Harris, A. J., 978, 983, 1026

Harris, A. L., 685

Harris, D. B., 201, 207

Harris, J. A., 547

Harris, W. W., 478, 501

Harrison, F. M., 991, 1026

Harrison, R., 238, 248

Harrower-Erickson, M. R., 234, 248, 249,

556, 579, 682, 687, 962, 966, 992, 1026

Harrowes, W., 869, 870, 876, 892, 914

Hart, B., 897, 914, 984, 1026, 1162

Hart, H. H., 195, 207, 817, 820

Hartman, H. R., 276, 300

Hartmann, G. W., 41, 45, 199, 207

Hartshorne, H., 25, 26, 45, 65, 67, 106, 133,

174, 175, 176, 178, 180, 191, 204, 207,

678, 687

Harvey, E. N., 479, 500, 1068, 1090, 1093,

1098

Haselhorst, G., 636, 650

Hastings, A. B., 592, 593, 617

Hastings, D., 885, 918, 1161

Hattwick, L. A., 674, 687

Hausmann, M. F., 184, 207, 353, 378, 1003,

1015, 1026

Haverson, H. M., 664, 666, 672, 686

Hawke, W. A., 1043, 1095

Hawthorne, J. W., 200, 207

Hayakawa, S. I., 133

Hayner, N. S., 738, 756

Hazlitt, V., 1026

Head, H., 292, 303, 551, 572, 574, 579, 989,

1008, 1009, 1011, 1026

Healy, H., 1015, 1026

Healy, M., 1148, 1159

Healy, W., 267, 326, 330, 703, 712, 785,

790, 798, 801, 804, 809, 810, 811, 812,

813, 814, 815, 819, 820, 821, 826, 832

Heath, C., 597, 598, 612

Heath, L. L., 39, 44

Heathers, G. L., 311, 322, 330

Heathers, L. B., 348, 378

Hebb, D. O., 558, 568, 570, 575, 579, 977,

988, 1014, 1026

Hecht, S., 598, 613

Hecker, E., 894, 914

Hedley, O. F., 281, 301

Heidenhain, R., 474, 491, 499

Heim, J. W., 586, 610

Hemphill, R., 896, 914

Henckel, K. O., 547

Henderson, D. K., 770, 790, 810, 820, 866,

870, 883, 886, 892, 905, 907, 914, 922,

927, 930, 936, 1145, 1159

Hendrick, I., 292, 303, 559, 579, 699, 712,

860

Henning, H. A., 184, 807

Henry, C. E., 418, 4*9, 1048, 1049, 1050,

1066, 1067, 1085, 1093, 1096, 1097

(Volume Ilpages 619 to 1191)

1202

AUTHOR INDEX

Henry, G. W., 270, 299, 867, 878, 881, 884,

892, 914, 921, 922, 927, 936

Henry, J., 655, 687, 7,94

Henschel, A. F., 599, 614

Henschen, S. E., 1009, 1011, 1026

Hepner, H. W., 194, 207

Heron, W. T., 589, 605, 611, 613

Herrick, C. J., 551, 579

Herrman, L., 512, 524

Herrnfeld, F. P., 1044, 109S

Hertz, M. R., 231, 232, 235, 248

Hertzman, M., 343, 378

Herzog, H., 42, 45

Hesketh, F. E., 23, 48, 533, 549, 863,

921

Hess, A. F., 54 7

Hetzer, H., 763, 790

Hewlett, T., 146, 167

Heymans, G., 182, 207, 457, 464

Hibler, F. W., 477, 499

Hildreth, G. H., 204, 207, 687

Hilgarcl, E. R., 53, 64, 67, 80, 83, 133,

341, 350, 378, 454, 464

Hill, H. F., 8/9

Hill, J. M., 687, 890, 914

Hill, L. B., 281, 301

Hilton, R., 592, 613

Himes, N., 1162

Himwich, H. E., 588, 599, 613, 614, 1064,

1093

Hinshelwood, J., 784, 790

Hinsie, L. E., 881, 920, 1154, 1159

Hinton, R. T,, Jr., 604, 613

Hippocrates, 526, 547

Hitchcock, C. W., 801, 820

Hitzig, E., 941, 965

Hnat, F., 547

Hoagland, H., 1035, 1043, 1045, 1059, 1064,

1067, 1079, 1082, 1093, 1094, 1100

Hobart, G., 479, 500, 1093, 1098

Hobbs, G. E., 512, 52 ',

Hobert, G., 1090

Hoch, A., 882, 883, 9/4, 998, 999, 1026

Hoch, P., 1084, 1094

Hoctor, E. F., 608, 617, 618, 884, 885,

910, 921

Hoeckstra, C. S., 1088

Hoelzel, F., 596, 613

Hoflf, E. C, 277, 300

Hoff, F., 592, 613

Iloff, H., 221, 248

Hoffman, W. C., 1080, 1094

Hoffmann, G. J., 184, 208

Hogben, L., 510, 512, 524, 525

Hohman, L. B., 778, 790

Hollander, B., 469, 473, 474, 478, 486, 491,

499

Hollingworth, H. L., 141, 150, 152, 153,

156, 167, 516, 524, 975, 977, 989, 1012,

1026

Hollingworth, L. S., 692, 712

Holt, E. B., 87, 133

Holt, L. E., 634, 650

Holzinger, K. J., 33, 45, 525

Homburger, A., 761, 790, 895, 914

Homburger, E. H., 734 (See Erikson,

E. H.)

Honzik, C. H., 308, 330

Hooton, E. A., 534, 547, 820

Hope, J. M., 1100

Hoppe, F., 333, 336, 339, 340, 347, 351, 378

Hoppock, R., 200, 208

Hopwood, A. T., 565, 579

Horn, D., 73, 133

Homey, K., 64, 67, 93, 113, 120, 121, 124,

133, 712, 7,74, 768, 790, 1120, 1132, 1159

Horowitz, E. L., 681, 687

Horowitz, R., 681, 687

Horst, P., 583, 613

Hoskins, R. G., 9, 46, 290, 291, 303, 606,

607, 613, 866, 890, 914

Houser, 885, 919

Hovey, H. B., 41, 46

Hovland, C. I., 64, 67, 68, 316, 317, 330,

332, 443, 444, 445, 464, 465

Howard, E. McC., 704, 712

Howard, F. E., 766, 790

Howard, W. T., Jr., 548

Howat, D., 546

Howell, I. L., 582, 611

Howells, T. H., 183, 208

Hrdlicka, A., 803, 820

Hubbard, L. D., 870, 916

Hubert, G., 607, 615

Hubert, W. H., deB., 1032

Huddart, J., 506, 524

Hufeland, C. W., 765, 790

Hug-Hellmuth, H., 772, 790

Hughes, J., 997, 1031, 1066, 1094

Hughes, J. E., 1174, 1191

Hull, C. L., 52, 53, 56, 64, 67, 69, 78, 81,

13,?, 151, 167, 225, 248, 313, 316, 330,

432, 4.34, 439, 441, 464, 46,7, 466, 469,

471, 472, 474, 475, 476, 478, 481, 483,

491, 497, 498, 499, 500, 999. 1007, 1015,

1026

Hull, H. L., 183, 209

Humm, D. G., 186, 208, 915

Humphrey, G., 415, 416, 418, 420, 421,

424, 425, 426, 428, 429, 508, 524

Hunt, E. L., 588, 614

Hunt, J. McV., 64, 67, 159, 167, 266, 268,

413, 414, 429, 445, 465, 622, 645, 650,

702, 711, 712, 889, 890, 895, 901, 903,

915, 972, 977, 986, 991, 995, 1002, 1004,

1005, 1012, 1013, 1015, 1016, 1019, 1026,

1029

Hunt, R., 870, 915

Hunt T., 175, 208, 1013, 1020, 1026

Hunt, W. A., 225, 248, 271, 298, 687, 1001,

1027, 1124, 1161

Hunter, M., 235, 248

Hunter, W. S., 52, 67, 386, 388, 865, 915

Hunting, L. M., 200, 211

Husband, R. W., 471, 498

Huse, B., 475, 500

Huston, P. E., 226, 248, 323, 330, 482, 500,

895, 915, 990, 993, 994, 996, 997, 998,

1004, 1026, 1030

Hutchings, R., 869, 915

Hutton, I. E., 1162

Hutton, J., 866, 915

Hutton, L., 1163

Hyland, H. H., 274, 299, 1035, 1094

Ilg, F. L., 664, 666, 672, 686

Ingle, D. J., 186, 208

(Volume I pages 1 to 618)

AUTHOR INDEX

1203

Ingram, M. E., 1130, 1159

Irwin, F. W., 344, 345, 378

Irwin, J. M., 459, 465

Isaacs, S., 652, 669, 681, 687, 993, 994,

1080, 1141, 1163

Ismail, Abd-El-Aziz, 281, SOI

Ito, G., 1056, 1094

Ivy, A. C., 599, 612

Jack, L. M., 671, 687

Jackson, J. H., 550, 575, 580, 1008, 1026

Jackson, T. A., 459, 465

Jackson, V. D.. 199, 208

Jacob, A., 559, 580

Jacobson, E., 1120, 1159

Jaensch, E. R., 20, 46, 547

Jaensch, W., 20, 46

James, E. B., 899, 920, 1031

James, W., 3, 5, 25, 46, 1U8, 1119, 1160

James, W. T., 81, 133, 391, 396, 397, 4*2

Jamieson, G., 880, 884, 915

Janet, P., 16, W, 431, 463, 465, 472, 485,

500, 888, 915, 1109, 1111, 1135, 1160

Janzen, R., 1036, 1072, 1073, 1075, 1076,

1094, 1096

Jaros, E., 987, 1031

Jarvis, L. L., 163, 167

Jasper, H. H., 187, 208, 561, 580, 770,

790, 867, 9/5, 1033, 1034, 1035, 1037,

1038, 1039, 1042, 1043, 1044, 1047, 1050,

1054, 1056, 1057, 1058, 1065, 1066, 1067,

1070, 1072, 1073, 1075, 1078, 1085, 1089,

1094, 1095, 1099, 1102

Jaspers, K., 892, 9/5

Jastak, J., 974, 975, 976, 982, 985, 986,

988, 1027

Jastrow, J., 13, J,6

Jebb, R. C., 13, 40

Jelliffe, S. E., 292, 293, 295, 303, 304, 305,

551, 580, 778, 790, 869, 875, 879, 904,

9/5, 957, 966, 1008, 1027

Jellinek, E. M., 293, 304, 606, 613, 890,

914, 1005, 1030

Jenkins, R. L., 594, 611, 614

Jenness, A., 474, 475, 479, 500, 50/, 1023

Jenness, M. D., 192, 208

Jennings, D., 722,, 734

Jennings, H. F., 158, 167, 505, 524

Jensen, F., 63, 68

Jensen, R. A., 762, 789

Jersild, A. T., 321, 330, 589, 614, 669, 671,

674, 684, 687, 782, 790

Jersild, C. L., 782, 790

Jetter, W. W., /090

Johns, G. A., 608, 6/7

Johnson, R. E., 597, 598, 612, 614

Johnston, H. M., 1027

Jolliffe, N., 599, 600, 614, 1146, 1/58

Jones, C, 273, 278, 300

Jones, C. M., 860

Jones, E., 491, 500, 624, 625, 650, 860,

1112, //60

Jones, E. S., 155, 167

Jones, H., 81, 134

Jones, H. E., 594, 598, 604, 617, 664, 687,

978, 987, 988, 1027

Jones, M. C., 684, 687, 692, 712

Jonesco-Sisesti, N., 1095

Joseph, H. H., 936

Josephy, H., 864, 9/5

Joslin, E. P., 590, 614

Jost, H., 687, 1059, 1090, 1095, 1101

Jucknat, M., 338, 339, 340, 343, 351, 356,

378

Jump, K. B., 587, 6/7

Jung, C G., 17, 4, 181, 208, 217, 220,

222, 223, 224, 225, 227, 246, 248, 249,

864, 868, 896, 9/5, 999, 1000, 1018, 1027,

1029, 1142, 1/60

Jung, R., 1035, 1039, 1044, 1045, 1073,

1095

Jurgens, B., 1060, 1095

K

Kahlbaum, K., 894, 915

Kahn, E., 546, 826, 832, 906, 909, 915,

932fT., 936

Kallmann, F. J., 520, 524, 863, 915

Kanner, L., 687, 761, 762, 763, 766, 768,

769, 770, 787, 790, 791, 889, 9/5, 1126,

//60

Kant, F., 867, 9/9, 987, /030, 1151, 1152,

1161

Kant, O., 894, 901, 915

Kaplan, N., 351, 378

Kapp, D. M., /030

Kappers, C. U. A., 567, 580

Kardiner, A., 61, 67, 292, 303, 655, 687,

734, 860

Karn, H. W., 420, 424, 425, 429, 450, 598,

6/5

Karn, M. N., 604, 6/7

Karnosh, L. J., 569, 580

Karpman, B., 810, 820, 957, 966

Kasahara, Y., 1056, 1094

Kasanin, J., 779, 787, 791, 891, 892, 902,

903, 9/4, 9/5, 1012, 1013, 1014, 1015,

1016, 1017, 1018, 1024, 1026, 1166, 1191

Katan, M., 1015, 1027

Katona, G., 51, 67

Katz, D., 57, 67, 91, 133, 192, 208

Katz, E., 319, 330

Katz, L. N., 281, 301

Katz, S. E., 189, 201, 208

Katzenelbogen, S., 1064, 1066, 1089, 1095

Kauders, O., 469, 474, 478, 486, 492, 498,

501

Kaufman, M., 274, 300, 787, 791

Kearns, W. M., 607, 6/7

Keeler, C. E., 525

Kehrer, F., 869, 906, 908, 909, 915

Keiser, F. L., 565, 579

Keister, M. E., 671, 687

Keller, A. D., 277, 300

Keller, A. G., 74, 135

Keller, M., 587, 615

Kelley, C. M., 897, 898, 920, 973, 974,

975, 976, 983, 984, 993, 994, 1032

Kelley, D. M., 233, 248, 991, 1027

Kelley, T. L., 34, 35, 40, 46

Kellogg, E. R., 475, 500

Kellogg, W. N., 455, 465, 546

Kellor, F. A., 803, 820

Kelly, E. L., 187, 208

Kemp, J., 290, 302

(Volume II pages 619 to

1204

AUTHOR INDEX

Kcndig, I., 864, 891, 898, 899, 900, 901,

902, 903, 915, 972, 973, 974, 975, 976,

978, 980, 981, 982, 983, 984, 985, 1004,

1027

Kennedy, F., 584, 617

Kennedy, M., 41, 46

Kent, G. H., 224, 226, 230, 248, 870, 897,

911, 915, 999, 1000, 1004, 1005, 1027

Kephart, N. C, 656, 687

Kerr, A. S., 1036, 1101

Kerr, W. J., 583, 584, 592, 614

Kerr, W. K., 1093

Kerschman, J., 1072, 1095

Keys, A., 599, 614

Keys, N., 200, 208

Kiernan, J. G., 800, 820

Kilpatrick, W. H., 90, 133

Kimball, O. P., 604, 61}

Kinder, E. F., 736

King, C. G., 425, 4%9, 430, 598, 616

Kinter, M., 198, 08

Kirby, G. H., 1125, 1160

Kirk, C. C., 565, 679

Kirkpatrick, F. H., 204, BOS

Kirkpatrick, M. E., 11 91

Kiss, P. V., 694, 614

Kitamura, K., 1056, 1096

Klages, L. f 15, 46

Klaue, R., 1068, 1096

Klebanoff, S. G., 444, 466, 972, 1027

Klee, J. B., 426, 429

Kleiber, M., 698, 614

Klein, D. B., 218, 221, 222, 239, 24#, 480, 600

Klein, M., 117, 127, 128, I33 t 627, 644,

650, 652, 687, 768, 772, 791, 874, 878,

915, 1141, 1149, 1160

Kleist, K., 551, 580, 891, 892, 902, 915,

1009, 1011, 1027

Kleitman, N., 1089

Klieneberger, O., 763, 791

Klineberg, O., 61, 67, 533, 547, 680, 687,

734, 739, 756

Klopfer, B., 228, 229, 230, 231, 233, 234,

2^7, 248, 250, 688, 991, 1027

Kluckhohn, C., 73, 78, 94, 95, 133, 73*

Kliiver, H., 565, 575, 580, 767, 791, 991,

1027

Knight, F. B., 152, 154, 167

Knight, R. P., 688, 868, 906, 916, 1147,

1154, 1160

Knopf, O., 292, 303, 1163

Knott, J. R., 867, 916, 1034, 1045, 1050,

1054, 1056, 1057, 1061, 1093, 1095,

1102

Knowles, E., 608, 610

Koch, H. L., 322, 330

Koch, J. L. A., 923, 927, 936

Kohler, L. H., 608, 617, 618, 921

Kohler, W., 51, 67, 70, 133, 734

Kohlstedt, K. D., 186, 209

Kohs, C. H., 224, 2*8

Koopman, L. J., 1091

Kopeloff, N., 866, 916, 1125, 1160

Korb, M., 1078, 1098

Kornhauser, A. W., 142, 143, 153, 167

Kornmuller, A. E., 1034, 1035, 1036, 1037,

1039, 1056, 1072, 1073, 1075, 1076, 1094,

1096

Korzybski, A., 104, 133

Kovsharova, T. V., 328, 330

Kraepelin, E., 16, 46, 810, 820, 866, 874,

875, 879, 883, 892, 896, 897, 916, 924,

936, 998, 999, 1004, 1015, 1027, 1109

Krafft-Ebing, R. von, 519, 524, 879

Kraines, R., 603, 611

Kraines, S. H., 592, 613, 878, 916, 1112,

1160

Kraiz, S. V., 990, 1027

Krasusky, W. S., 533, 547

Krause, L. S., 225, 248

Krechevsky, I., 308, 310, 311, 330

Kreezer, G. L., 416, 429, 1034, 1086, 1096

Kreindler, A., 1095, 1098

Kretschmer, E., 21, 22, 23, 46, 530, 531.

547, 797, 820, 841, 860, 863, 906, 907,

909, 916

Kriaschew, W. J., 605, 614

Krisch, H., 1018, 1027

Kroeber, A. L., 716, 734

Krogman, W. M., 547

Kronfeld, A., 901, 916

Krout, M. H., 60, 68, 109, 122, 133, 135,

146, 167, 752, 756

Krueger, R. G., 475, 500

Krugman, M., 228, 235, 248, 249

Kubie, L. S., 64, 67, 270, 295, 298, 305,

484, 490, 499, 628, 651

Kubis, J., 1084, 1094

Kugelman, I. N., 547

Kugelmass, N., 953, 966

Kulchar, G. V., 289, 302

Kiilpe, O., 19, 46

Kunze, B., 184, 208

Kwallwasser, J., 198, 208

Lachman, S. E., 770, 791

Laehr, H., 15, 46

Laidlaw, R. W., 1101

Laird, D. A., 186, 208

Lallemand, C. F., 765, 791

Lamar, N., 870, 920

Lambert, A., 1146, 1160

Lamoreaux, R. R., 75, 82, 84, 134

Landes, R., 734

Landis, C, 147, 167, 189, 200, 201, 208,

225, 248, 271, 298, 701, 712, 740, 756,

863, 895, 909, 916, 987, 1001, 1002,

1006, 1015, 1023, 1024, 1027, 1028, 1124,

1150, 1160, 1161

Landolt, H., 605, 614

Lang, J., 1002, 1016, 1028

Lang, T., 519, 524

Langdon-Down, J., 521, 524

Lange, J., 864, 869, 906, 916

Langford, W. S., 783, 784, 791

Langworthy, O. R., 628, 650

Lankes, W., 182, 208

Lasegue, 274, 300

Lashley, K. S., 565, 573, 575, 580

Lasswell, H. D., 327, 328, 330, 331, 726,

734

Last, S. L., 587, 614, 895, 916

Lathers, E., 43

Latz, L. J., 1163

Laugier, H., 1037, 1096

Lauterbach, C., 512, 524

Lavater, J. C., 547

(Volume / pages 1 to 618)

AUTHOR INDEX

1205

Lawrence, C. H., 608, 616

Lawrence, E. M., 512, 524

Lawrence, M., 598, 614

Lawson, F. L., 1093

Laycock, T., 547

Lazarsfeld, P. F., 165, 167

Leach, J., 690

Leahy, A. M., 775, 790

Lebensohn, Z., 865, 916

Lederer, R., 547

Lee, D. D., 734

Leedham, C. L., 585, 614

Leeper, R., 321, 332

LeFort, R., 604, 614

Lehman, H. C., 194, 208

Lehrman, S., 899, 916

Leiter, L., 281, 301

Lemere, F., 1047, 1049, 1050, 1076, 1079,

1081, 1083, 1096, 1146, 1162

Lendrum, F., 882, 916

Lennox, E. L., 586, 590, 592, 614, 618

Lennox, W. G., 292, 303, 521, 524, 938,

942, 943, 944, 945, 946, 950, 951, 952,

953, 959, 966, 1048, 1064, 1069, 1072,

1073, 1074, 1075, 1091, 1092, 1097, 1099

Lentz, T. F., 42, 46

Lenz, F., 509, 524

Leonard, S. T., 605, 612

Lerique, J., 1087

Lerner, E., 657, 660, 661, 672, 673, 674,

687

Leshnew, N. F., 293, 304

Lesko, J. M., 1091

Lessa, W. A., 534, 548

Lester, O., 146, 167

Leuba, C., 478, 481, 500

Levey, H. B., 299, 320, 331

Levin, H. L., 1165, 1191

Levin, M., 550, 580, 901, 916

Levine, K., 1089

Levine, M., 275, 299, 300

Levy, D. M., 92, 105, 133, 234, 240, 242,

249, 266, 268, 290, 303, 622, 640, 645,

650, 652, 653, 655, 658, 681, 688, 762,

772, 774, 775, 782, 787, 788, 791, 820,

1148, 1160, 1177, 1191

Levy, G., 734

Levy, J., 130, 133, 791, 1132, 1160

Levy, N. A., 1086, 1097

Levy, R. J., 677, 688

Levy-Bruhl, L., 901, 916

Lewald, J., 599, 614

Lewerenz, A. S., 198, 208

Lewi, B., 653, 664, 671, 686

Lewin, B., 866, 916

Lewin, K., 12, 43, 46, 50, 64, 67, 70, 84,

125, 131, 133, 161, 165, 167, 199, 208,

314, 316, 317, 329, 331, 379, 387, 432,

434, 465, 653, 671, 688, 1018, 1022

Lewin, Y., 756

Lewis, A., 869, 870, 881, 916

Lewis, C., 655, 676, 688

Lewis, H. B., 342, 378

Lewis, N. D. C, 244, 249, 270, 298, 863,

864, 866, 870, 916, 1110

Lewis, R. A., 1094

Lewton, G., 131, 133

Lewy, F. H,, 586, 617

Liberson, W., 1034, 1037, 1038, 1047, 1052,

1058, 1089, 1096, 1097, 1099

Liberson, W. T., 1064, 1097

Libet, B., 588, 614, 1035, 1037, 1091, 1097

Lidbetter, E. T., 518, 524

Liddell, H. S., 98, 131, 281, 301, 391, 396,

397, 412, 413, 416, 429, 575, 580, 584,

614, 867, 916

Lidz, T., 1028

Light, R. N., 277, 300

Likert, R., 199, 209

Liljenerants, J., 992, 1007, 1028

Lind, A. W., 756

Lind, J. E., 991, 1028

Lindeman, E. C., 755

Linder, F. E., 218, 223, 249

Linder, G. C., 592, 613

Lindesmith, A., 756

Lindgren, E. J., 734

Lindner, S. L., 764, 791

Lindsley, D. B., 418, 421, 425, 427, 429,

1038, 1039, 1041, 1045, 1047, 1050, 1053,

1054, 1056, 1060, 1061, 1063, 1065, 1066,

1067, 1080, 1085, 1097

Line, W., 985, 989, 1028

Linton, R., 72, 78, 84, 133

Lipofsky, H., 437, 465

Lippitt, R., 316, 317, 331, 671, 688

Lippman, H. S., 687, 809, 810, 820

Lipschtitz, A., 9, 46

Liquier, A., 1034, 1089

Liss, E., 245, 249, 680, 688

Lissner, K., 320, 331

Livanov, M. N., 1056, 1097, 1100

Liveing, E., 938, 952, 963, 966

Lodowski, C. H., 425, 429

Loevenhart, A. S., 593, 614

Logan, G. B., 1074, 1098

Lombroso, C., 529, 547, 802, 820, 823, 832

Long, J. A., 168

Longmoor, E., 756

Loomis, A. L., 479, 500, 1034, 1038, 1044,

1047, 1048, 1053, 1056, 1058, 1060, 1067,

1068, 1090, 1093, 1098

Looney, J., 890, 914

Loosli-Usteri, M., 234, 249

Lorand, A., 290, 303

Lorand, S., 290, 302

Lord, E. E., 779, 791

Lorenz, W. F., 593, 614

Lorge, L, 182, 189, 201, 208

Lorimer, F., 756

Lottier, S., 756

Loufbourow, G. C., 200, 208

Lourie, R. S., 675, 685

Louttit, C. M., 761, 766, 786, 791

Love, A. G., 740, 756

Lovell, H. W., 1056, 1098

Low, A. A., 1152, 1160

Low, B., 1163

Lowden, G. L., 974, 975, 1023

Lowenbach, H., 1048, 1074, 1075, 1096

Lowenberg, K., 587, 614

Lowenfeld, M., 240, 249, 660, 688

Lowenstein, P., 671, 688

Lowery, H., 198, 208

Lowrey, L. G., 687, 688, 772, 791, 794, 808,

814, 817, 820

Lucas, W. P., 88, 133, 547

Ludlum, S. D. W., 591, 615

Ludwig, E., 553, 580

Luff, N. C., 608, 615

(Volume II pages 619 to 1191)

1206

AUTHOR INDEX

Lugoff, L. S., 225, 248

Luithlen, W. F., 184, 208

Lund, F. H., 117, 133

Lundborg, H. B., 521, 524

Lundeen, G. E., 198, 206, 209

Lundholm, H., 181, 208, 478, 494, 500, 890,

916, 993, 1008, 1028

Luria, A. R., 224, 225, 226, 229, 249, 481,

482, 500

Lurie, L. A., 290, S03 t 605, 609, 615, 769,

771, 791

Lurie, W. A., 578

Lutherman, C. Z., 607, 610

Lydston, G. F., 802, 820

Lyerly, J. G., 581, 618, 865, 916, 1032

Lyman, R. S., 548, 1036, 1063, 1098

Lynd, R. S., 73, 133

Lyon, I. W., 506, 524

M

MacCurdy, J., 491, 500, 883, 884, 914, 916

MacFarland, R. A., 41, 46

Macfarlane, J. W., 653, 663, 664, 667, 675,

682, 688

Machover, S., 755

MacKensie, C. N., 1163

Mackenzie, M., 1030

MacKinnon, D. W., 17, 28, 44, 46, 471,

498, 688

MacNitt, R. D., 186, 208

Macrae, T. F., 421, 428

MacRobert, R. J., 957, 966

Macy, I. G., 599, 612

Maeder, L. M. A., 820

Magaret, G. A., 341, 378, 986, 987, 1928

Mahler, W., 320, 331

Maier, N. R. F., 414, 415, 416, 417, 418,

420, 421, 422, 424, 425, 426, 429, 507,

524, 584, 615

Maijgren, R., 41, 48

Mailloux, N. M., 996, 1028

Malamud, W., 218, 223, 249, 785, 7.91, 853,

860, 867, 870, 899, 916, 917, 975, 977,

983, 984, 985, 986, 991, 1028, 1100, 1102

Malinowski, B., 72, 73, 106, 133, 162, 167,

695, 712, 717, 734, 764, 791

Mailer, J. B., 27, 46, 176, 179, 182, 185,

189, 192, 196-197, 198, 200, 204, 205,

207, 208, 209, 678, 687, 756

Malzberg, B., 525, 702, 712. 756, 863, 872,

873, 917, 918, 1151, 1152, 1160

Man, E. B., 546

Mandelbaum, J., 598, 613

Mannin, E., 1163

Manouvrier, L., 547

Manson, G. E., 194, 209

Maranoa, G., 615

Marcuse, F., 399, /,12, 416, 418, 419, 420,

424, 426, 429, 508, 524

Marcuse, L., 5, 46

Margolin, S. G., 1072, 1080, 1091, 1098

Margulies, H., 234, 248, 688

Marimes, J. C., 604, 614

Marinesco, G., 1061, 1064, 1068, 1078, 1079,

1098

Markey, F. V., 669, 674, 687, 782, 790

Marmor, J., 1078, 1092, 1098, 1101

Marquis, D. G., 53, 64, 67, 80, 83, 133, 454,

464

Marquis, D. P., 87, 133, 621, 650

Marrow, A. J., 480, 499

Marshall, C., 558, 580

Marshall, H., 1146, 1158, 1160

Marston, L. R., 42, 46, 186, 209

Martin, A. J. P., 421, 7/28

Martin, C. J., 421, 428

Martin, H. A., 1006, 1032

Martin, R. F., 310, 312, 331, 416, 417, 419,

420, 421, 426, 428, 429

Martinson, B. M., 1098

Maslow, A. H., 187, 209, 379, 388

Mason, G., 323, 331

Mason, H. L., 597, 598, 618

Masserman, J. H., 74, 133, 236, 237, 238,

246, 249, 275, 294, 300, 305, 403, 405,

406, 408, 410, 411, 412, 576, 580, 834, 860

Mateer, F., 605, 615

Mathers, A. T., 1170, 7/91

Matthews, B. H. C., 1034, 1035, 1037, 1038,

1040, 1043, 1044, 1054, 1056, 1087, 1098

Maudsley, H., 823, 832, 938, 958, 966

Maughs, S., 810, 820

Maurer, K. M., 39, 46

Maury, A., 218, 249

May, J., 820, 898, 917

May, M. A., 25, 26, 45, 65, 67, 75, 104, 106,

133, 134, 140, 168, 174, 175, 176, 178,

180, 191, 199, 204, 207, 678, 687

Mayer-Gross, W., 895, 896, 917

Mayo. E., 104, 134

Mays, L. L., 895, 916, 987, 1024

Mazick, S. G., 584, 612

McAdory, M., 198, 209

McBee, M., 703, 712

McBride, K. E., 978, 1008-1011, 1082

McCance, R. A., 608, 615

McCay, J. G., 688

McClatchy, V. R., 200, SOB

McClean, M., 1103

McClenahan, B. A.. 756

McQoy, C. H., 39, 46, 547

McCollum, E. V., 91, 134

McConnell, T. R., 78, 134, 186, 206

McCormick, H. W., 688

McCormick, M. J., 199, 209

McCulloch, W. S., 965, 1037, 1090

McDermott, N. T., 286, 288, 302

McDonald, C. A., 1078, 1098

McDonald, J. W., 603, 615

McDonald, W., 900, 917

McDougall, W., 5, 7, 46, 70, 134, 431, 465,

474, 500, 1110, 1111, 1160

McFarland, M. B., 688

McFarland, R. A., 187, 209, 585, 586, 588,

611, 615, 867, 870, 917, 1018, 1028, 1146,

1160

McGaven, A. P., 590, 615

McGehee, W., 354, 378

McGeoch, J. A., 78, 81, 134, 200, 209

McGraw, M. G., 688

McHale, K., 194, 209

McKay, H. D., 741, 743, 745, 757

McKee, L., 690

McKenzie, R. D., 756

McLean, H. V., 286, 301

McMahon, J. F., 1050, 1082, 1098

McManomy, M., 885, 919

McNeel, B. H., 1098

McNemara, W. J., 187, 209

(Volume I pages 1 to 618)

AUTHOR INDEX

1207

Mead, G. H., 109, 134

Mead, M., 73, 93, 94, 105, 107, 109, 110,

115, 119, 122, 126, 134, 627, 650, 655,

685, 695, 712, 719, 727, 728, 729, 731,

732, 733, 734

Meduna, L. V., 1123, 1152, 1160

Meek, L. H., 1168

Meier, C. A., 227, 2//9

Meier, N. C., 198, 209

Meige, H., 781, 791

Meikeljohn, A. P., 597, 598, 612

Mekeel, S., 734

Melbo, I. R., 688

Melcher, R. T., 522, 523, 779, 790

Mellanby, E., 598, 615

Melton, A. W., 459, 465

Meltzer, H., 227, 2//9, 321, 331

Menninger, K. A., 113, 134, 284, 285, 286,

289, 301, 302, 796, 809, 820, 1/6,?

Menninger, W. C., 273, 279, 285, 290, 300,

301, 302, 303, 779, 79*, 1130, 1100

Menzies, W., 866, 917

Mergener, J. C., 1090

Merritt, H, H., 949, 953, 966, 1074, 1099

Mesmer, F. A., 473, 500, 1109, 1110

Messerschmidt, R., 475, 500

Meyer, A., 290, 303, 587, 61!,, 763, 769,

791, 862, 868, 869, 874, 884, 887, 889,

890, 891, 905, 906, 907, 9/7, 1019, 1028,

1110, 1125, 1126, 1160, 1191

Meyer, B. C., 1092

Meyer, M., 874, 918

Meynert, T., 550, 580

Miale, F. R., 234, 249, 682, 687

Michael, J., 797, 820

Michaels, J. J., 688, 974, 975, 1028

Middleton, W. C., 43, 45

Mierke, K., 324, 331

Miles, C. C, 187, 200, 208, 212, 518, 525

Miles, W. R., 313, SSI, 988, 102$

Millard, M., 982, 1030

Miller, C. H., 198, 209

Miller, D. C., 199, 200, 209

Miller, E., 547, 860, 1112, 1160

Miller, H., 595, 616

Miller, M. L., 281, 284, 286, 301

Miller, N. E., 52, 53, 56, 64, 66, 67, 68, 78,

79, 80, 81, 84, 103, 113, 134, 313, 315,

316, 318, 319, 529, 331, 332, 379, 388,

432, 434, 437, 439, 440, 441, 450, 461,

462, 463, 465, 607, 615, 735

Miller, W., 867, 869, 892, 916, 917

Miller, W. R., 293, 304

Millichamp, D. A., 685

Mills, R. W., 547

Miner, J. B., 194, 209

Minkowski, M., 622, 631, 650

Mintzer, M. G., 344, 345, 378

Mion, R. J., 1087

Mira, E., 245, 249

Miskolczy, D., 1028

Mitchell, N. B., 475, 500

Mitchell, S. W., 1118, 1160

Mittelmann, B., 327, 331, 722, 735

Mohr, G. J,, 533, 5//7, 688

Molitch, M., 604, 609, 615

Moll, A., 472, 474, 478, 483, 491, 498, 500,

786, 791

Money-Kyrle, R. E., 93, 95, 134, 624, 627,

650

Moniz, E., 864, 917

Monroe, M., 784, 791

Monroe, R., 130, 133, 1132, 1160

Montgomery, R. P., 183, 210

Moore, A. U., 399, 412, 419, 429

Moore, B. V., 144, 167

Moore, E. H., 321, ,531

Moore, H., 142, 143, 145, 168

Moore, M., 953, 965, 984, 1146, 1160

Moore, T. V., 39, 46, 985, 989, 1007, 1028

Moorman, L. J., 594, 615

Morel, B., 893, 917

Morel, F., 990, 1028

Moreno, J. L., 158, 159, 168, 243, 249, 679,

688

Moreno, S. L., 123, 134

Morgan, C. D., 199, 209, 235, 237, 238, 2//9

Morgan, C. T., 415, 419, 420, 423, 424, 429

Morgan, J. D., 415, 419, 420, 429

Morgan, J. J. B., 183, 186, 207, 209, 688,

1163

Morgan, L. H., 718, 735

Morgenstern, S., 245, 249

Moricard, R., 682, 685

Morison, B. R., 1099

Morison, R. S., 1037, 1090

Moro, E., 632, 650

Morris, A., 796, 820

Morrison, G. W., 605, 615

Morrow, R. S., 198, 209

Morse, M., 866, 917

Moschcowitz, E., 275, 290, 300, 303

Mosier, C. I., 39, 46, 195, 212

Mosse, E, P., 244, 2//6, 249

Motokawa, K., 1056, 1098

Mott, F., 864, 866, 898, 917

Mowrer, E. R., 756

Mowrer, H., 1163

Mowrer, O. H., 52, 53, 56, 64, 66, 68, 73,

74, 75, 78, 79, 81, 82, 84, 94, 99, 125,

133, 134, 135, 312, 315, 319, 321, 329,

3J1, 379, 388, 451, 462, 465, 1018, 1028

Moynihan, B., 865, 917

Mudd, E. H., 1130, 1160

Mufson, J. A., 1099

Muhl, A. M., 897, 917, 987, 1028

Mullaney, O. C., 587, 616

Miiller, G. E., 17, 46

Miiller, L. R., 1068, 1099

Miiller, M., 1151, 1152, 1161

Muncie, W., 551, 580, 869, 889, 891, 917,

918, 922, 927, 936, 1015, 1028, 1126,

1161

Munn, C., 882, 895, 918

Munro, D., 557, 580, 1076, 1078, 1092

Murchison, C., 621, 650, 684

Murphy, G., 43, 46, 49, 63, 68, 97, 134, 148,

168, 199, 209, 652, 663, 670, 672, 674,

688, 999, 1028

Murphy, L. B., 43, 46, 49, 68, 97, 114, 134,

148, 162, 168, 652, 656, 657, 659, 660,

661, 663, 668, 669, 670, 672, 673, 674,

687, 688

Murphy, M., 689

Murphy, W. F., 1099

Murray, C., 278, 300

Murray, H. A., 4, 12, 17, 40, 43, 44, 47, 70,

79, 98, 134, 143, 148, 149, 166, 168, 185,

197, 200, 210, 229, 233, 235, 237, 238,

249, 324, 331, 471, 472, 498, 500

(.Volume II pages 619 to 1191)

1208

AUTHOR INDEX

Murray, H. H., 199, 209

Murray, J. M., 712

Mursell, G., 1028

Myers, C. R., 1098

Myers, G. C, 774, 792

Myerson, A., 507, 524, 525, 863, 869, 918

N

Naccarati, S., 529, 5*7

Nacht, S., 279, SOO

Nadel, A B. 1012, 1029

Nadel, S F., 7,15

Neill, A S, 1161

Neisser, C, $96, 9/8

Nesin, S., 599, 613

Neumann, G. B., 192, 210

Nevin, S., 1103

Newburger, M., 996, 1028

Newcomb, T. M., 41, 47, 49, 68, 97, 134,

148, 152, 159, 168, 199, 210, 652, 663,

672, 674, 688

Newell, H. W., 240, 242, 249, 775, 792

Newman, H. H., 510, 516, 524, 525

Newman, H. W., 1034, 1099

Newsletter, W. L, 140, 159, 168

Neymann, C. A., 186, 210

Nichols, I. C, 587, 615, 977, 992, 1005,

1012, 1013, 1028, 1073, 1075, 1095, 1099

Nicholson, N. C., 474, 500

Nielsen, J. M., 562, 572, 573, 575, 580

Niles, C., 869, 918

Nimkoff, M., 737, 740, 756

Nims, L. F., 558, 580, 1072, 1092, 1099

Nims, L. G., 1091

Nissen, H. W., 735

Nissl, F., 864, 918

Noiseaux, P. J., 1087

Noll, V. H., 199, 210

Norbury, F. G., 599, 615

North, E. A., 821

Notkin, J., 869, 918, 955, 966

Nowlis, H. H., 320, 324, 331

Noyes, A., 810, 821, 863, 885, 888, 892,

894, 908, 918

Nunberg, H., 698, 712, 860

Nygard, J. W,, 479, 500, 991, 1028

Qberholzer, E., 231, 250

Obermann, C. E., 1058, 1099

Oberndorf, C. P., 290, 302, 874, 918

Obersteiner, H., 993, 1029

O'Brien, J. D., 587, 615

O'Connor, J., 182, 210

Odbert, H. S., 44, 50, 66

Oden, M., 1031

Ogburn, W. F., 737, 740, 756

Ogden, C. K., 84, 134

Ogden, W., 866, 910

O'Kelly, L. I., 312, 313, 331

Oldham, H. W., 689

O'Leary, J., 1037, 1088, 1089

Olesen, R., 604, 615

Olmsted, J. M. D., 598, 615

Olson, E., 1002, 1029

Olson, W. C, 42, 47, 189, 210

Oribe, M. F., 1087

O'Rourke, L. F., 184, 210

O'Rourke, L. J., 145, 147, 168

Orton, S. T., 769, 783, 792, 1018, 1029

Osborn, F., 756

Osborne, R., 901, 918

Osgood, W. B., 770, 792

O'Shea, H. E., 597, 615

Osier, W., 1131, 1/61

Otis, M. A., 183, 210

Ovsiankina, M., 319, 331 (See Riclcers-

Ovsiankina, M.)

Owen, M. B., 740, 752, 756

Pacella, B. L., 1035, 1086, 1099

Page, D. P., 186, 210

Page, J. D., 199, 210, 327, 331, 421, 4%$,

701, 712, 740, 756, 863, 909, 916, 1001,

1027, 1150, 1160

Page, R. M., 671, 689

Pagniez, P., 1099

Pai, T., 5^8

Pallister, H., 187, 210

Palmer, E. M., 899, 916, 983, 984, 985, 986,

1028

Palmer, G., 785, 791

Palmer, H. D., 865, 870, 885, 918, 920,

1123, 1153, 1154, 1161

Papanicolaou, G. N., 291, 303, 608, 616,

885, 919

Papez, J., 576, 580

Pappenheim, M., 763, 792

Paracelsus, 270, 298

Park, R. E., 736, 741, 756

Parker, M. M., 424, 429, 508, 524

Parmenter, R., 281, 301, 392, 396, 407, 408,

410, 411, 584, 610, 834, 860

Partington, J. E., 980, 1029

Partridge, E. DeA., 147, 168, 694, 695, 712

Partridge, G. E., 810, 821, 823, 826, 832,

874, 886, 911, 918, 923, 931, 936

Paskind, H. A., 873, 918, 952, 957, 966

Paterson, D. G., 194, 210, 533, 547

Patrick, J. R., 604, 615

Patry, F. L., 766, 790

Patten, E. F., 475, 500

Patterson, H. A., 953, 966

Patterson, M. B., 608, 612, 1002, 1023,

1158

Patterson, R. J., 821

Pattie, F. A., Jr., 477, 494, 500

Patton, R. A., 415, 420, 423, 424, 425, 429,

430, 598, 615

Patty, F. A., 587, 618

Paulian, D., 1084, 1099

Paulsen, A., 689

Pavlov, I. P., 75, 134, 270, 273, 276, 277,

298, 389, 390, 407, 408, 4^2, 416, 480,

459, 465, 478, 500, 550, 553, 580, 780,

792

Payntor, 766, 792

Payot, J., 1117, 1161

Peabody, R. A., 1147, 1161

Pear, T. H., 42, 47

Pearl, R., 547, 548

Pearl, R. D., 547

(J'olume I pages 1 to 61 a>

AUTHOR INDEX

1209

Pearson, G. H., 290, 302, 689, 884, 918

Pearson, K., 506, 509, 510, 516, 524, 548

Peatman, J. G., 198, 210

Peden, G. W., 590, 615

Peiper, A., 628, 635, 636, 650

Pelletier, M., 896, 918

Pende, N., 529, 548

Penfield. W., 558, 566, 568, 570, 575, 579,

580, 941, 966, 977, 1026, 1072. 1099

Penrose, L. S., 511, 519, 524

Pentsik, A. S., 1078, 1100

Peritz, G., 780, 792

Pertsch, C. F., 200, 210

Peters, R. A., 597, 616

Peterson, R, 224, 225, 249, 1000, 1029

Peterson, R. C., 325, 331

Peterson, W. F., 548

Pfaffmann, C., 1005, 1029

Pfister, H. O., 244. 249

Phelps, W. N., 522, 523, 779, 790

Phleger, M., 756

Piaget, J., 652, 678, 689, 900, 901, 902, 918

Pickford, R. W., 239, 249

Pignet, 548

Piker, P., 882, 918

Pillsbury, D. M., 289, 302

Pillsbury, W. B., 15, 47

Pilzecker, A., 46

Pinard, J. W., 182, 210

Piness, G., 595, 616

Piotrowski, Z., 232, 234, 249, 556, 580, 899,

900, 916, 918, 984, 985, 986, 1002, 1020,

1024, 1029

Plant, J. S., 57, 68, 162, 168, 679, 689, 776,

792

Plattner, W., 5//8

Plesset, I. R., 525

Plichet, A., 1099

Polatin, P., 1099

Pollock, H. M., 525, 756, 765, 789, 863,

882, 918

Pollock, L. J., 960, 966, 1002, 1029

Poole, M. W., 599, 612

Popenoe, P., 128, 134, 1163

Poppelreuter, W., 992, 1029

Porteus, S. D., 183, 210, 983, 1029

Posteli, T., 1079, 1099

Postle, B., 1161

Pototzky, C., 781, 792

Potter, H. W., 238, 247, 761, 765, 787,

789, 792

Potzl, O., 221, 248, 902, 918

Poull, L. E., 183, 210, 953, 966

Powell, E., 590, 616

Powell, M., 689

Prados y Such, M., 1035, 1099

Pratt, K. C., 621, 629, 631, 650

Preda, G., 1029

Pressey, L. C., 181, 210

Pressey, S. L., 181, 195, 210, 897, 918, 974,

976, 983, 984, 1029

Preston, M. G., 345, 350, 351, 378

Preston, M. I., 680, 689

Preu, P. W., 930, 936

Preu, W., 279, 299

Prichard, J. C., 799, 821, 823, 832, 923, 937

Prince, M., 4, 47, 218, 249, 431, 465, 479,

495, 500

Prinzhorn, H., 244, 249

Proctor, L. D., 1098

Pryor, H. B., 547

Pumpian-Mindlin, E., 1029

Putnam, T. J., 525, 949, 950, 953, 966,

1074, 1099

Quackenbos, J. D , 474, 501

Queen, S. A., 749, 756

Quensel, F., 990, 1029

Quinn, J. A., 756

Rabin, A. I., 919, 984, 985, 986, 1029

Rachlin, H., 882, 919

Radcliffe-Brown, A. R., 717, 735

Radin, P., 716, 735

Rado, S., 834, 853, 860, 875, 878, 919

Rae, S. F., 59, 67

Rahm, W. E., Jr., 956, 966, 1036, 1038,

1040, 1044, 1076, 1086, 1099, 1101, 1102

Rahman, L., 274, 300

Rajka, T., 594, 614

Ramirez Moreno, S., 1035, 1099

Raney, E. T., 1048, 1099

Rank, O., 87, 134, 626, 650

Ransom, J. B., 801, 821

Ranson, S. W., 571, 580

Rapaport, D., 235, 250

Raphael, T., 591, 616, 863, 919

Rappaport, E., 685

Raskin, N., 587, 616

Rasmussen, E. W., 438, 465

Raths, L. E., 197, 210

Rawlings, E., 897, 901, 919, 974, 984, 985,

1001, 1006, 1016, 1029

Ray, I., 799, 821

Raymond, A. F., 881, 911, 991, 1023, 1154,

1158

Razran, G. H. S., 53, 68, 325, 331, 1006,

1029

Ream, M. J., 181, 195, 210

Rechetnik, J., 1006, 1028

Reckless, W. C., 746, 756, 813, 821

Reed, A. Y., 144, 168

Reed, G., 864, 913

Reed, S., 735

Reichenberg, W., 689

Reichert, F. L., 606, 612

Reichline, P. B., 43, 45

Reichmann, F., 551, 557, 579

Reifenstein, E. C., 1146, 1159

Reik, T., 121, 134

Reinhardt, J. M., 131, 134

Reiss, E., 901, 919

Reitman, F., 244, 250

Reitmann, F., 588, 612

Remmels, V., 200, 213

Remmers, H. H., 155, 168, 191, 194, 199,

200, 213

Rennie, T. A. C., 869, 870, 919, 920, 1015,

1031

Renshaw, B., 1037, 1099

Rethlingshafer, D., 183, 210

Reuder, N., 870, 917

Rexroad, C. N., 5, 47

Reyburn, H. A., 39, 47

(Volume II pages 619 to 1191)

1210

AUTHOR INDEX

Reynolds, D., 1159

Reynolds, M. M., 762, 792

Rheinberger, M. B., 1099

Rhoades, W., 1163

Rhyne, J. J., 756

Ribble, M., 640, 650

Rich, G. I., 591, 616

Richards, E. L., 783, 787, 793

Richards, I. A., 84, 90, 134

Richards, T. W., 689, 779, 790

Richardson, C. A., 181, 210

Richardson, F. H., 1163

Richardson, H. B., 274, 300

Richardson, M. W., 475, 501

Richman, E., 690

Richmond, W. V., 712, 864, 891, 898, 899,

900, 901, 902, 903, 915, 972, 973, 974,

975, 976, 978, 980, 981, 982, 983, 984,

985, 1004, 1027, 1163

Jtichter, C. P., 91, 135, 400, 412, 602, 603,

616, 618, 1002, 1029

Rickers-Ovsiankina, M., 233, 250, 1003,

1029

Rickman, J., 869, 919

Ricksher, C., 897, 919

Riddle, E. E., 478, 50*

Riddle, O., 603, 616

Riemer, M. D., 689

Riess, B. F., 595, 616

Riess, B. R., 689

Riggs, A. F., 1127, 1129, 1131, 1154, 1161,

1163

Riggs, L. A., 993, 994, 996, 997, 1026

Rilger, C., 474, 501

Rioch, M., 5^8

Riplcy, II. S., 274, 300, 608, 616, 885, 919

Rippon, T. S., 1120, 1161

Rippy, E. L., 548

Ritala, A. M., 548

Rivers, T. D., 1146, 1158, 1161

Rivers, W. H. R., 431, 465, 719, 735

Roback, A. A., 8, 12, 13, 15, 47, 171, 210

Roberts, J. A. F., 509, 512, 524, 594, 613

Roberts, W. H., 80, 135

Robinson, G. W., Jr., 1146, 1161

Robinson, J. H., 1132, 1161

Robinson, L. J., 1048, 1074, 1099

Robinson, V. P., 162, 168

Robison, S. M., 743, 756

Rodclis, L., 281, 301

Rodnick, E. H., 994, 1029

Roe, A., 972, 973, 974, 975, 976, 977, 978,

980, 981, 982, 984, 985, 1011, 1029, 1032

Roens, B. A., 204, 211

Roethlesberger, F. J., 57, 68

RofT, L., 669, 689

Roff, M., 669, 689

Roffenstein, G., 218, 221, 250

Rogers, C. R., 186, 210, 787, 792, 1148,

1161

Rogers, G. G., 779, 792

Rogerson, C. H., 240, 241, 242, 250, 286,

302

Rogerson, C. R., 773, 792

Roheim, G., 87, 126, 135, 624, 627, 650,

735, 878, 901, 919

Rohracher, H., 1034, 1040, 1041, 1056,

1057, 1100

Romano, J., 1072, 1100

Romero, L. F., 1087

Root, A. R., 186, 210

Rorschach, H., 19, 47, 215, 227, 228, 231,

250

Rosanoff, A. J., 181, 182, 186, 210, 224,

226, 230, 248, 518, 520, 525, 874, 919,

978, 999, 1000, 1027, 1030

Rosanoff, I., 1030

Rose, A., 1091

Roseman, E., 599, 610

Rosen, G. P., 987, 1015, 1023

Rosenbaum, M., 599, 610

Rosenblueth, A., 1037, 1100

Rosenfeld, M., 622, 636, 650, 651

Rosenow, C., 469, 494, 501

Rosenzweig, S., 64, 68, 189, 199, 210, 233,

239, 241, 250, 323, 331, 379, 383, 386,

387, 388, 894, 919

Rosner, A., 958, 964

Ross, D. A., 1065, 1080, 1100

Ross, H., 687, 112

Ross, T. A., 860, 1154, 1155, 1161

Ross, W. H., 200, 08

Rostan, L., 527, 548

Rothbart, H. B., 604, 616

Rothermich, N. O., 1153, 1161

Rothney, J. W. M , 204, 211

Rothschild, D., 5(53, 564, 580

Rotter, J. B., 236, 237, 238, 250, 333, 349,

,978

Rouvroy, C., 972, 1030

Rowe, A. W., 9, 47, 608, 616

Rowe, S. N., 977, 1030

Rowland, L. W., 487, 501

Rowles, E., 604, 615

Rubenstein, B. B., 273, 200, 291, 299, 303,

608, 611, 1047, 1063, 1065, 1097

Rubin, M. A., 1037, 1038, 1047, 1064, 1065,

1066, 1067, 1079, 1082, 1086, 1093, 1094,

1100

Rubin, S., 1051, 1100

Ruch, F. L., 211, 1163

Rudin, E., 520, 525

Rudnick, J., 953, 966

Rugg, H., 150, 151, 152, 153, 168

Rundquist, E. A., 191, 211

Runkel, J. E., 184, 211

Ruppert, H., 763, 792

Rush, B., 799, 821, 822, 832

Russel, J. T., 987, 1032

Ryans, D. G., 204, 211

Ryder, H. W., 599, 610

Rylander, G., 556, 568, 580, 582, 616, 972,

977, 1030

Sachs, B., 768, 792

Sackett, R. S., 311, SSI

Sacks, J., 418, 425, 429

Sadger, J., 293, 304

Sager, O., 1078, 1095, 1098, 1100

Sailer, R. C., 199, 211

Sait, E. M., 341, 350, 378

Sakel, M., 1123, 1151, 1161

Sampson, M. B., 822, 832

Samuel, E. A., 204, 212

Sanders, M. J., 64, 68, 312, 33*

Sandiford, P., 155, 168

Sanford, R. N., 237, 250, 324. 332

(Volume I pages 1 to 618)

AUTHOR INDEX

I2II

Sapir, E., 755

Sarbin, T. R., 232, 250, 471, 499

Sargant, W. W., 1089

Sarkisov, S. A., 1078, 1100

Sassaman, W. H., 1060, 1097

Saul, L. J., 269, 272, 273, 281, 282, 283,

284, 288, 289, 290, 298, 300, 301, 302,

584, 610, 1050, 1051, 1100

Saunders, E. B., 993, 994, 1030

Savitsky, N., 1078, 1098, 1101

Sayers, R. R., 587, 618

Sayles, M. B., 164, 168, 775, 792, 1132,

1161

Scarff, J. E., 1036, 1038, 1040, 1076, 1101

Schachtel, E., 689

Schackter, M., 1034, 1101

Schaffer, G., 473, 474, 498, 499

Scharf, M. P., 735

Scheerer, M., 903, 914

Schilder, P., 64, 68, 469, 471, 474, 478, 486,

492, 498, 501, 666, 667, 689, 755, 789,

8*9, 867, 890, 895, 910, 919, 990, 992,

1002, 1006, 1008, 1023, 1030, 1110, 1111,

1113, 1138, 1140, 1161

Schiller, M., 769, 792

Schilling, M. E., 974, 975, 1028

Schlosberg, H., 413, 414, 416, 418, 420, 428,

429, 1005, 1029

Schmelvkin, D. G., 1035, 1101

Schmid, C. F., 747, 756

Schmidl-Waehner, T., 661, 689

Schmied, M., 273, 300

Schneck, M. R., 140, 167

Schneider, A., 919

Schneider, C., 894, 896, 901, 919

Schneider, K., 924, 937

Schoen, M., 5, 47

Scholl, R., 19, 47

Schott, A., 875, 919

Schott, E. L., 605, 616, 973, 974, 975, 1030

Schou, H. L, 588, 6/6

Schreiber, F., 587, 6*6

Schreiber, S. L., 604, 6*6

Schrenk, H. H., 587, 618

Schroeder, P. L., 779, 792

Schrotter, K., 218, 221, 222, 250

Schube, K., 244, 246, 250

Schube, P. G., 885, 919, 1153, 1161

Schulte, H., 906, 919

Schultz, E., 590, 615

Schulz, V. E., 281, 301

Schwab, E. H., 281, 301

Schwab, R. S., 1065, 1072, 1073, 1078,

1080, 1089, 1100, 1101

Schwartz, A., 281, 293, 301

Schwartz, H. G., 1036, 1101

Schwartz, L. A., 174, 211

Schwartz, O., 293, 304

Schwarz, R., 898, 919, 980, 1030

Scott, H. D., 475, 481, 501

Scott, R., 285, 301

Scott, W. D., 151, 168

Scow, R. O., 586, 617

Scripture, E. W., 993, 1030

Searle, O. M., 591, 616, 863, 919

Sears, P. S., 64, 68, 316, 332, 344, 345, 350,

352, 378

Sears, R. R., 64, 66, 68, 152, 156, 168, 307,

313, 315, 316, 317, 319, 321, 322, 323,

325, 326, 327, 329, 330, 332, 340, 378,

379, 388, 443, 444, 445, 464, 465, 476,

501

Seashore, C. E., 198, 209, 211

Sebrell, W. H., 595, 600, 616

Secunda, L., 1085, 1101

Sedgwick, W., 506, 525

Segal, J., 1056, 1092, 1101

Segalis, M., 1092

Segel, D., 204, 211

Seibel, M., 690

Seidemann, H., 1053, 1064, 1089

Seidenari, R., 1079, 1099, 1101

Seidenfeld, M. A., 200, 211

Seitz, C. P., 187, 209, 586, 611

Seleye, H., 385, 388

Seligman, C. G., 720, 735

Semeonoff, B., 198, 211

Scrota, H. M., 1035, 1043, 1082, 1093, 1097,

1101

Seward, G. H., 608, 616

Seymour, A. H., 596, 616

Shaffer, L. F., 52, 68, 78, 135

Shagass, C., 1056, 1095

Shakow, D., 226, 239, 241, 248, 250, 323,

330, 482, 500, 890, 894, 898, 910, 914,

919, 972, 973, 974, 975, 976, 977, 978,

980, 981, 982, 983, 984, 985, 988, 993,

994, 996, 997, 998, 1004, 1006, 1023,

1026, 1029, 1030

Shand, A. F., 5, 47

Shapiro, H. D., 1152, 1161

Shapiro, L., 882, 919

Sharp, A. A., 322, 332

Sharp, F. C., 174, 211

Sharp, M. L., 563, 564, 580

Shaw, C. R., 741, 743, 745, 746, 757, 775,

792

Shaw, F. C., 533, 548

Shaw, R. F., 245, 250

Sheehan, D., 277, 300

Sheerer, M., 1010, 1012, 1013, 1005

Sheffield, A. E., 163, 168

Sheldon, C P., 510, 525

Sheldon, J. H., 274, 300

Sheldon, W. H., 91, 135, 529, 537 ff, 548,

841, 860, 863, 919

Shelton, P., 1161

Sherif, M., 57, 68

Sherman, I. C., 4, 47, 757

Sherman, M., 4, 47, 689, 757, 1059, 1101

Sherman, S., 885, 918, 1161

Sherrington, C. S. t 288, 295, 302, 305, 400,

412, 456, 465, 550, 580

Shipley, W. C., 867, 895, 902, 916, 919,

981, 983, 987, 1006, 1015, 1030, 1151,

1152, 1161

Shirley, H. F., 770, 781, 792

Shirley, M., 655, 656, 659, 664, 689

Shock, N. W., 584, 586, 589, 591, 592, 593,

594, 596, 598, 604, 605, 613, 614, 616,

617, 867, 919

Shorr, E., 608, 616, 885, 919

Shuttleworth, F. K., 195, 211, 678, 687, 689

Sidis, B., 1120, 1161

Sigaud, C., 548

Signori, E., 420, 426, 428

Silberer, H., 220, 250

Silverman, B., 774, 792

Simmins, C., 978, 981, 1006, 1030

Simoneit, M., 147, 149, 168, 184, 185, 211

(Volume // pages 619 to 1191)

1212

AUTHOR INDEX

Simonson, E., 599, 607, 617

Siris, J., 1099

Sisk, H. L., 420, 450

Sjaardema, H., 1078, 1092, 1093

Skalweit, W., 864, 919

Skccls, H. M., 656, 689

Skinner, B. F., 52, 53, 67, 68, 239, 250, 310,

332, 589, 613

Skinner, C. E., 684

Skoglund, C. R., 1053, 1088

Skorodin, B., 519, 523

Sleeper, F. H., 293, 304, 890, 914, 1005,

1030

Sletto, R. F., 191, 211

Slight, D., 292, 304

Sliosberg, S., 320, 332

Sloane, P., 884, 913

Slotkin, J., 903, 920

Slye, M., 548

Small, M. H., 757

Smick, A. A., 738, 757

Smith, B. F., 597, 598, 618

Smith, G., 762, 792, 1183, 1191

Smith, G. E., 572, 579

Smith, J. R., 1039, 1053, 1054, 1089, 1101

Smith, K. U., 415, 416, 417, 419, 420, 423,

424, 425, 427, 430

Smith, L., 870, 884, 913 f 920

Smith, L. H., 594, 611

Smith, R. B., 187, 211

Smith, S., 431, 465

Smith, W. W., 225, 250

Snee, T. J., 418, 420, 425, 430

Snow, A. J., 183, 211

Snyder, F. F., 622, 636, 650, 651

Snyder, L. H., 548

Soley, M. H., 584, 587, 592, 614, 617

Sollenberger, R. T., 129, 135, 689, 694,

712

Solomon, A. P., 281, 301, 895, 912, 1090

Solomon, C I., 1085, 1089

Solomon, H. C, 593, 612, 987, 1024, 1091

Solomon, J. C, 240, 250, 1148, 1161

Solomon, P., 561, 580, 770, 790, 936, 1095

Solomon, R. L., 159, 167

Somerfeld-Ziskind, E., 953, 966

Somers, G. T., 154, 168

Sommerville, R. C., 548

Sonquist, D. W., 194, 211

Sorokin, P. A., 740, 757

Sos, 605, 617

Soto Romay, R., 1101

Southard, E., 864, 920

Southard, H. F., 155, 167

Spadavecchia, R., 595, 612, 770, 789

Spalding, M. A., 654, 685

Spaulding, E., 804, 821

Spearman, C. E., 17, 29, 30, 33, 47, 182,

211, 897, 914, 984, 1026

Spencc, K. W., 52, 68, 452, 465

Spencer, D., 187, 199, 211

Spielberg, P. I., 1034, 1056, 1101

Spielman, W., 146, 168

Spielmeyer, W., 864, 920

Spies, T. D., 599, 600, 613, 617

Spiesman, I. G., 592, 615

Spitz, R. A., 755

Spitzka, E. C., 800, 821, 823, 832

Spoerl, D. T., 246, 250

Sprague, G. S., 821, 901, 920

Spranger, E., 548

Spratling, W. P., 953, 966

Spurzheim, J. G., 528, 548

Squires, P. C, 1020, 1030

Ssucharewa, G. E., 533, 548

Stagner, R., 49, 60, 68, 109, 122, 135, 155,

181, 204, 211, 321, 552, 712

Stainbrook, E. J., 415, 417, 418, 420, 421,

430

Stalker, H., 869, 870, 920

Stalnaker, J. M., 475, 478, 501

Starr, H. E., 591, 617

Staub, H., 810, 819

Stauder, K. H., 961, 966

Stauter, J. J., 200, 211

Stead, E. A., Jr., 1100

Stearns, A. W., 826, 852

Steegmann, A. T., 587, 615

Steggerda, M., 517, 525

Stein, R., 864, 920

Stein, W. E., 558, 580

Steinach, E., 607, 617

Steinberg, D., 866, 915

Steinberg, J., 604, 617

Steiner, G., 864, 920

Steniner, V., 690

Stephen, K., 1016, 1050

Stephenson, W., 182, 211, 987, 988, 989,

1050

Stern, W., 4, 15, 19, 47, 235, 250, 652,

689

Stern-Piper, L., 548

Stevens, S. S., 538ff., 542ff., 5/,8, 863, 919

Stevenson, G. S., 762, 792, 1178, 1191

Stevenson, P. H., 533, 548

Stevenson, S. S., 316, 331, 462, 465

Stewart, W. B., 1101

Stier, E., 786, 792

Stiller, B., 548

Stockard, C. R., 507, 525, 548

Stocks, A. V., 604, 617

Stocks, P., 604, 617

Stokes, J. H., 288, 289, 502

Stoll, H. F., 606, 617

Stone, A., 1165

Stone, C. P., 603, 617, 682, 689, 693, 718

Stone, H. M., 1165

Stone, L., 295, 505

Stonescu, T., 1029

Storch, A., 891, 901, 920, 1016, 1050

Stotler, W. A., 576, 580

Stott, L. H., 695, 715

Stout, E., 685

Strang, R., 199, 211

Stransky, E., 864, 868, 869, 890, 891, 896,

920

Strauch, A., 783, 792

Strauss, A. A., 656, 687

Strauss, H., 956, 966, 1001, 1050, 1045,

1048, 1064, 1074, 1085, 1086, 1097, 1098,

1099, 1101, 1102, 1124, 1161

Strecker, E. A., 431, 4^5, 833, 860, 865,

870, 883, 920, 922, 927, 957, 997, 1051,

1094, 1134, 1H7, 1150, 1158, 1161

Street, R., 991, 1051

Strickler, C. B., 475, 501

Strom-Olson, R., 895, 916

Stromberger, K., 636, 650

Strong, E. K., 193, 195, 211, 996, 998,

999, 1001, 1051

(.Volume I pages 1 to 618)

AUTHOR INDEX

1213

Strongin, E., 881, 920

Stuart, H. C, 683, 689

Stubbs (Stubbe), H., 473, 501

Studman, L. G., 39, 47, 1031

Stumbur, E. D., 1003

Stump, N. F., 200, 211

Sturges, H. A., 996, 103%

Sullenger, T. E., 757

Sullivan, A. J., 278, 279, 299, SOO

Sullivan, E. B., 595, 616, 953, 955, 966

Sullivan, H., 869, 870, 892, 920

Sulzbach, W., 1045, 1086, 1090

Sulzberger, B., 685

Sulzberger, M., 290, 302

Sumner, W. G., 74, 135

Sung, S. M., 548

Sunne, D., 234, 250

Super, D. E., 189, 211

Sutherland, E. H., 743, 757

Sutherland, G. F., 412, 584, 617

Sutton, A. C., 548

Svendsen, M., 671, 688

Sweet, L., 191, 212

Swineford, F., 212

Switzer, S. A., 475, 500

Sydenstricker, V. P., 599, 612, 617

Symonds, C. P., 574, 575, 576, 577, 580

Symonds, P. M., 150, 152, 161, 168, 194,

204, 207, 212, 224, 227, 250, 660, 681,

689

Symons, N. J,, 995, 1031

Tabori, J., 1147, 1161

Talbot, E. S., 802, 821

Tallman, F. F., 242, 243, 250

Tallman, G., 234, 250

Tatarenko, N. P., 1018, 1031

Taylor, E. A., 756

Taylor, J. G., 39, 47

Taylor, W. S., 7, 47, 320, 332

Taylor, Z. E., 1100

Teagarden, F. M., 983, 1024

Tedstrom, M. K., 590, 617

Tegelberg, J. J., 1094

Tendler, A. D., 181, 182, 212, 975, 977,

1001, 1031

Terence, C. F., 418, 4*0

Terman, L. M., 174, 187, 200, 208, 212,

518, 525, 898, 920, 978, 1031

Terry, G. C., 869, 870, 920, 1015, 1031

Therman, O., 1045, 1102

Thiele, R., 778, 792

Thorn, D. A., 777, 781, 792, 1132, 1148,

1161, 1162, 1163

Thomas, D. S., 42, 47, 737, 757

Thomas, L. C., 779, 792

Thomas, L. F., 756

Thomas, M., 238, 250

Thomas, W. I., 42, 47, 746, 757

Thomas, W. S., 589, 614

Thompson, C. B., 805, 808, 809, 811, 813,

819

Thompson, H., 621, 643, 650, 672, 686

Thompson, J., 899, 921, 1015, 1017, 1018,

1019, 1031, 1032

Thompson, J. W., 1090, 1102

Thompson, L. A., 186, 200, 212

Thompson, W. S., 757

Thorns, H., 547

Thomson, G. H., 34, 47

Thomson, M. M., 1061, 1102

Thomson, W. A., 197, 212

Thorley, A. S., 617

Thorn, G. W., 1094

Thorndike, E. L., 70, 78, 135, 182, 195,

200, 208, 212, 512, 525, 565, 580

Thorndike, R. L., 148, 168

Thorner, M., 1052, 1102

Thorner, M. W., 586, 617

Thornton, G. R., 183, 212

Thorpe, L. P., 170, 212

Thrasher, F. M., 743, 757

Thurstone, L. L., 33, 36, 39, 47, 186, 189,

191, 195, 212, 325, 331, 332, 573, 581,

582, 617

Thurstone, T. G., 212

Tiebout, H. M., 1172, 1191

Tiegs, E. W., 170, 212

Tillotson, K. J., 1147, 1159

Tilney, F., 628, 651

Tissot, S. A., 765, 793

Titeca, J., 1084, 1102

Titley, W., 884, 920

Tobin, F. J., 420, 426, 428

Todd, T. W., 548

Tolman, R. S., 511, 523

Toman, J., 1056, 1102

Tonnies, F., 757

Tonnies, J. F., 1039, 1044, 1102

Torrents, 1035, 1044, 1078, 1102

Tosisada, M., 1056, 1098, 1102

Touraine, G. A., 274, 276, 292, 299, 304,

682, 685, 963, 966

Touro del Pino, J., 1031

Tracy, H. C., 269, 298

Trapp, C. E., 770, 792, 885, 899, 919, 920,

974, 1031

Traube, T., 245, 250

Travis, L. E., 783, 793, 990, 995, 1024,

1031, 1045, 1047, 1056, 1058, 1095, 1108

Travis, R. C, 184, 212, 990, 1031

Trawick, M., 42, 47, 199, 212

Traxler, A. E., 204, 212

Treadgold, H. A,, 548

Tredgold, A. F., 800, 821

Troup, E., 662, 689, 962, 966

Trow, W. C., 41, 47, 184, 199, 212

Trowbridge, E. H., Jr., 1090, 1102

Tryon, R. C., 35, 47, 507, 525

Tscherning, R., 548

Tschernorutzky, M. W., 548

Tucker, W. B., 534, 538ff., 548, 863, 919

Tudor, M., 1099

Tulchin, S. H., 743, 757, 762, 791, 806,

807, 808, 821

Turner, E., 1064, 1100

Turner, R. H., 414, 427, 430

Tuttle, H. S., 192, 209

Twyeffort, L. H., 1130, 1162

u

Uhrbrock, R. S., 181, 212

Updegraff, R., 671, 687, 689

Uray, T., 273, 300

Usher, S. J., 1078, 1102

{Volume II pages 619 to 1191)

1214

AUTHOR INDEX

Valentine, C. W., 242, 250

Valentine, P. F., 4, J7, 74, 185

Van der Heide, C, 277, 293, 294, 300, SO*

Van der Horst, 51,8

Van der Molen, 1066, 1109

Van Dusen, A. C., 195, 212

Van Liere, E. J., 585, 586, 617

Van Wagener, N. B., 187, 212

Varendonck, J., 217, 250

Varnum, W. H., 198, 212

Varvel, W. A., 233, 251

Veo, L., 1166, 1191

Vernon, P. E., 4, 7, 8, 35, 37, 41, 42, 43,

44, 47, 146, 157, 168, 184, 185, 188, 195,

205, 21S, 227, 229, 233, 246

Vigotsky, I. S., 891, 892, 898, 902, 920,

1012, 1016, 1017, 1019, 1031

Viola, G., 528, W

Vittoz, R., 1117, 1162

Vivian, M., 1146, 1162

Voegtlin, W. L., 1146, 1147, 1162

Voelker, P. F., 175, 213

Vogel, F., 675, 685

Vogt, C., 581

Vogt, O., 581

Voice of Experience, 1165

Volkman, J., 341, 377

Vollmer, H., 548

von Monakow, 550, 566, 581

Von Rohdev, F., 5^8

Voronoff, S., 604, 617

W

Wadsworth, G. W., 186, 208

Waelder, R., 131, 135, 239, 251

Walden, E. C, 479, 501

Waldman, H., 415, 429

Walker, K. F., 70, 135

Walker, L., tf

Wall, C, 1086, 1100

Wall, J., 880, 884, 915

Wallace, W. M., 1063, 1064, 1090

Waller, J., 274, 300

Waller, W. W., 160, 168

Wallin, J. E. W., 953, 967, 983, 1031

Walsh, J. J., 1117, 1118, 1162

Walsh, M. N., 1035, 1103

Walter, C. W. P., 1089, 1101

Walter, W. G., 1033, 1034, 1035, 1036,

1041, 1050, 1076, 1078, 1082, 1086, 1089,

1091, 1092, 1098, 1103

Wang, C. K. A., 187, 213

Warden, A. N M 421, 425, 428

Warkentin, J., 327, 331

Warner, W. L., 719, 735

Warren, H. C, 4, 8, 48, 466, 501

Warstadt, A., 5^8

Washburn, R. W., 662, 664, 690

Washburne, J. H., 200, 213

Waters, R. H., 321, 332

Waters, R. M., 593, 614

Watson, G. B., 186, 192, 199, 204, 207,

213

Watson, J. B., 4, 5, 48, 74, 135, 768, 769,

798

Watson, M. L., 422, J30

Watson, R. I., 199, 213

Watts, J. W., 277, 300, 551, 570, 571, 579,

864, 865, 868, 913, 920, 977, 102$, 1091,

1125, 1146, 1153, 1159

Wauthier, M. L., 183, 206

Webb, E., 39, 48

Webb, E. T., 1163

Weber, C. B., 41, 48

Wechsler, D., 183, 213, 582, 617, 972, 973,

976, 978, 986, 987, 1002, 1007, 1031

Wechsler, H., 797, 820

Wechsler, I. S., 617, 860

Weech, A. A., 786, 793

Wegner, W. R., 1076, 1078, 1092

Wegrocki, H., 891, 903, 920, 1013, 1015,

1016, 1031

Weidenreich, F., 5^/9

Weigl, E., 1012, 1031

Weinbach, A. P., 1053, 1054, 1103

Weis, M. W., 608, 617

Weisenburg, T., 978, 1008, 1009, 1010,

1011, 1031

Weisman, S. A., 5^9

Weiss, E., 281, 284, 286, 287, 301, 302

Welch, L., 480, 501

Wellman, B. L., 656, 689, 690

Wells, F. L., 181, 213, 215, 227, 231, 233,

235, 251, 314, 332, 897, 898, 920, 973,

974, 975, 976, 983, 984, 989, 993, 994,

996, 998, 1000, 1001, 1006, 1032

Wells, W. R., 469, 470, 473, 476, 484, 487,

488, 494, 497, 501

Welti, J., 1087

Wentink, E. A., 589, 617

Wentworth, M. M., 898, 902, 921, 974,

975, 984, 985, 1016, 1032

Werner, A. A., 608, 617, 618, 884, 885,

891, 910, 921, 1153, 1162

Wernicke, C., 550, 581

Wertham, F., 5^9, 560, 581, 875, 921

Wertham, F., 560, 581

Wertheimer, F., 23, 48, 533, 5^9, 863, 921

West, R., 783, 793

Westphal, K., 276, 300, 5^9

Wexberg, E., 768, 793

Wheeler, R. H., 51, 68, 81, 135

Wheeler, W. M., 98, 135, 5^9

Whelen, M., 866, 910

Whipple, G. M., 514, 525

Whisler, L., 199, 200, 213

Whitaker, J. E. F., 596, 616

White, A. D., 1108, 1162

White, B., 273, 278, 300

White, B. V., 860

White, M. M., 471, 501

White, R. C, 757

White, R. K., 317, 331, 671, 688

White, R. R., 183, 187, 213

White, R. W., 472, 478, 492, 494, 495,

496, 501

White, W. A., 1016, 1032

Whitehead, A. N., 717, 735

Whitehill, J. L., 1130, 1160

Whitehorn, J. C., 270, 298

Whiting, J. W. M., 92, 99, 100, 106, 119.

125, 135, 735

Whitman, R. H., 186, 213

Whittenberger, J., 597, 598, fi!2

Whitwell, J., 874, 921

Whitwell, S. R., 270, 298

(Volume 1 pages 1 to 618)

AUTHOR INDEX

1215

Wholey, C. C, 801, 821

Wible, C. L., 474, 479, 500, 501

Wickens, C, 87, 135

Wickens, D. D., 87, 135, 598, 618

Wickert, F., 42, 48

Wickman, E. K., 775, 793

Widdowson, E. E., 608, 615

Wiener, A. S., 514, 525

Wiersma, E. D., 182, 207, 213, 978, 985,

986, 988, 1032

Wigton, R., 1094

Wilbur, D. L., 1146, 1162

Wilder, R. M., 597, 598, 618

Wildermuth, H., 900, 921

Wile, I. S., 1163

Wilkins, L., 602, 618

Wille, W., 763, 793

Willemse, W., 533, 549

Williams, A. C, Jr., 1036, 1057, 1058,

1099, 1103

Williams, D., 1076, 1078, 1079, 1092, 1099,

1103

Williams, F. E., 1132, 1162, 1164, 1191

Williams, G. W., 475, 501

Williams, H. M., 39, 48, 656, 689

Williams, R. D., 597, 598, 618

Williams, R. J., 600, 618

Williams, S. B., 309, 311, 332

Williams-Ellis, A., 1163

Williamson, E. G., 162, 165, 168, 169

Willins, F. A., 285, 302

Willoughby, R. R., 56, 68, 118, 135, 186,

213, 2G8, 694, 713, 978, 1032

Wilmanns, K., 921

Wilson, A. T., 276, 299

Wilson, C. W., 279, 300

Wilson, G. W., 280, 289, 299, 302

Wilson, R., 163, 169

Wilson, R. T., 757

Wimberly, S., 195, 212

Windle, W. F., 588, 618

Wingfield, H. E., 474, 498, 501

Winkelstein, A., 275, 300

Winn, R. B., 469, 474, 491, 501

Wirth, L., 757

Wishart, G., 895, 913

Witkin, H. A., 414, 430

Witmer, H. L., 72, 135, 690, 1167, 1183,

1191

Wittkower, E., 271, 278, 285, 286, 298,

301, 302

Wittman, G., 869, 918

Wittman, M. P., 869, 898, 921, 979, 980,

987, 1004, 1005, 1032

Witty, P. A., 208, 690

Wobus, R. E., 293, 304

Wohlgemuth, A., 321, 332

Wolf, A., 584, 617

Wolf, A. W. M., 98, 135, 1163

Wolfe, J. B., 80, 135, 310, 332

Wolfe, T. P., 280, 281, 302

Wolfe, W. B., 1143, 1162

Wolff, H. G., 327, 331, 592, 618, 735, 963,

964, 967

Wolff, W., 43, 48

Wolfle, D. L., 34, 37, 39, 40, 48, 452, 464

Woltman, H t W., 1103

Woltmann, A. G., 243, 246, 773, 789, 1148,

1158

Womack, N. A., 589, 613

Woodger, J. H., 104, 135

Woodrow, H., 39, 48, 174, 200, 213

Woods, W. L., 1015, 1032

Woodworth, R. S., 6, 48, 70, 135, 181, 185,

213, 517, 525

Wooster-Drought, C., 953, 967

Worchel, P., 581, 618, 1032

Wortis, H., 597, 618, 636, 651

Wright, B. P., 325, 332

Wright, H. W., 801, 821, 1163

Wright, M., 1163

Wright, V., 204, 213

Wright, W., 869, 915

Wulff, M., 273, 301

Wundt, W., 8, 48

Wylie, M., 1007, 1032

Wyman, J. B., 194, 213

Wynn-Jones, L., 182, 213

Yacorzynski, G. K., 353, 378, 982, 985,

1032

Yamagiwa, K., 1036, 1038, 1087

Yant, W. P., 587, 618

Yeager, C. L., 1035, 1050, 1076, 1083,

1103

Yeakel, E., 419, 423, 428

Yellowlees, H., 474, 501

Yerkes, R. M., 972, 974, 978, 1032

Yoakum, C. S., 5, 48

Yoder, F. R., 738, 757

Young, C. W., 995, 1031

Young, E. F., 756

Young, K,, 109, 135

Young, M., 549

Young, P. C., 474, 475, 479, 484, 492,

498, 502

Young, R. A., 165, 169

Youtz, R. E. P., 309, 311, 332

Zachry, C. B., 713

Zalowitz, E., 43, 45

Zbinden, T., 587, 614

Zeigarnik, B., 319, 332

Zeleny, L. D., 158, 169

Ziegler, L. H., 510, 525, 864, 881, 920, 921

Ziehen, G. T., 767, 793

Zilboorg, G., 270, 299, 699, 713, 867, 921

Zimand, G. F., 1171, 1190

Zimmerman, C. C, 740, 757

Ziskind, E., 953, 966

Znaniecki, F., 168

Zorbaugh, 738, 746

Zubin, J., 189, 200, 201, 208, 899, 921,

1015, 1019, 1032

Zucker, H., 661, 690

Zuker, K., 1032

Zweig, A., 868, 921

Zweig, H., 549

Zyve, D. L., 199, 213

(Volume II pages 619 to 1191)

SUBJECT INDEX

(Volume I pages 1 to 618; Volume II pages 619 to 1191)

Ability,

abstract,

brain lesions and, 1012

continuum of, 1013

criticism of concept, 1013

psychotic vocabulary and, 981

tests of, 1012

capacity vs., 985

general (g), psychosis and, 981

Abnormality,

culture and, 722

degrees of, 892

delinquency and, 797

migration and, 738

Abreactipn,

definition of, 1135

dissociation and, 1111

therapy and, 1156

"Abstraction age," 902, 981

Absurdities,

paretic performance on, 985

schizophrenic vs. paretic performance on,

1020

Acid-base, behavior and balance, 591

Acidity,

blood,

behavioral effects of, 592

intellectual effects of, 593

Act-habits, 55

personality traits as, 50

Action,

primitivation of, 314

style of, 55

Action-goal, 335

Activity, diurnal,

experimental neurosis and, 413

Acts,

definition of, 51, 55

goal of, 56

movements vs., 50

Acuity, visual, hypnotic improvement of,

474

Adaptation, adjustment and, 71

Adjustment,

adolescent,

case illustrations of, 704

disorders in, 701

dynamics of, 698, 700

psychoanalytic theory of, 698

associative learning and, 52

childhood patterns of, 681

physiological factors in, 682

situational weighting in, 682

habit, 58

drive and, 59

language and, 84

learning theory and, 71

parental confidence and, 695

personality as habit-adjustment, 58

Ad j ustment Continued

programs fostering, 1184

sexual, dynamics of, 695

tests of, 180

urban vs. rural experience and, 695

variability of response and, 54

vocational, 130

Adolescence,

anthropological study of, 719

asceticism in, 708

behavior disorders in, incidence of, 701

biological drive and social demands in,

129

case studies of, 704

family emancipation in, 127

Hall's treatise on, 691

homosexual tendencies in, 694

interest changes in, 693, 704

literary productions, 707

masturbation in, 694

parental antagonism in, 129, 706

parental interference, case illustrations,

706

physiological development in, 692

psychosexual dynamics at, 698

Rankian theory of, 700

sexuality in, 127, 693, 705

transitory neurosis in, 708

Adrenalin,

behavior after injections of, 589

blood sugar regulation and, 601

Affect hunger, 655, 774

Age,

abstraction (Shipley), 902, 981

developmental, Furfey test of, 694

mental, deficit in terms of, 973

response to new experience and, 672

vocabulary test,

deficit and, 979

discrepancy between mental age and,

982

Aged,

abilities last in the, 987

deficit in the, 978

deficit pattern in the, 987

efficiency index in the, 980

Aggression, 112

adolescent, sexual frustration and, 696

cannibalism and, 113

change of form in, 318

childhood, forms of, 669

crime and, 817

death instinct and, 112

displacement of, 317

fatigue and, 125

frustration and, 113, 315

learning of, 53

quantitative relations in, 316

sexuality, inhibition of, and, 118

socialization and, 112

taboo of, 125

1217

I2l8

SUBJECT INDEX

Aggressiveness,

child-differences in, 665

experiences producing, 673

Agnosia, 573

Albinism, heredity of, 515

Alcoholism,

drug therapy in, 1146

psychiatric treatment of, 1145

Alexia, 573, 1009

Alkalinity,

behavioral effects of, 591

respiration and, 592

tetany and, 591

well-being and, 592

Allergy, intelligence and, 594

Allopsychic, 550

Alpha, per-cent-time, 1044

Alzheimer's disease, 562

Ambiguous perspective, manic-depressive

psychosis and, 991

Ambivalence, culture and, 72

Amentia, heredity of, 506

Amplifiers, electrical, 1043

Analysis,

distributive, synthesis and, 1126

dream, 218

of psychological phenomena, experimen-

tal, 306

Anesthesia,

EEG in, 1065

hypnotic, 473

modern experiments on, 476

Angina pectoris, 280

Animals,

conditioning in, 395

conflict in, 413, 451

defects of studies of, in personality re-

search, 646

EEG in, 1034, 1037

experimental neurosis in, 389, 402, 413

feeding experiments on, and infantile ex-

periences, 643

life history studies, 622

Anomia, 573

Anorexia nervosa, 274

Anoxia,

behavioral effects of, 585

carbon monoxide and, 587

EEG with, 1062

infantile, 635

judgment and, 585

long-continued, effects of, 588

nitrous oxide and, 587

permanent effects, 586

repeated exposure effects, 586

senescence and, 589

Anthropology,

behavior classification in, 730

child education studies in, 724

childhood experience approach in, 726

choice of variables, 716

common traits assumed in, 719

criminal, 801, 803

cultural, 715

evolutionary theory in, 715

explanatory concepts in, 715

family relations and learning in, 719

functional, 717

kinship systems in, 718

personality description in, 720

Anthropology Continued

personality theory and, 85

social,

learning and, 71

personality dynamics, and, 68

psychoanalysis and, 71

social structure in, 718

Anthropometry, 528

crime and, 534

Anxiety,

avoidance responses in, 451

conflict and, 451

experimental neurosis and, 405

frustration and, 380, 385

hyperyentilation and, 592

infantile pleasure strivings and, 626

sexuality as escape from, 117

symptoms and, 626, 853

turgesence of skin and, 628

Apathy, schizophrenic, 890

Aphasia,

abstract ability and, 1009

brain damage and. 572, 1011

congenital, 784

history of, 1008

inheritance of, 514

present status of knowledge, 1009

semantic, 553

Aphonia, 848

Aplasia, 564

Application forms, 141

Appollonian, dichotomy of Dionysian and,

720

Appraisal, personality (See "Personality,

assessment and appraisal of")

Apraxia, 573

Arapesh, family relationship, 726

Areas,

culture, 716

delinquency, 742

Arithmetic progression, schizophrenics, 1020

Art,

children's, 243

expression, prompted, for diagnosis and

therapy, 245

psychological study of, 243

psychotic, 244

Asphyxia, birth, 636

Aspiration level, 333

action goal and, 335

attitudes and, 353

choice in, 356

confidence level and, 335

conflict in, 356

definition, 333

determinants, 337

development of, 354

discrepancy score, 347

events in experiments on, 334

generality of measures, 349

goal discrepancy, 335

group standards and, 340

individual differences in, 346

past achievement and, 371

personal traits and, 351

rationalization and, 375

reality level and, 344

reference scales, 337, 358, 366

schizophrenic, 1003

socio-economic background, 343

(Volume I pages 1 to 618)

SUBJECT INDEX

1219

Aspiration level Continued

success and failure and, 337, 361, 373

theoretical considerations, 356

valences in experiment on, 356

Assessment,

personality,

autobiography in, 143

case study method of, 160

methods of German military psychol-

ogists, 149

objective test methods of, 214

projective methods of, 214

rating methods, 150

Rorschach test in, 227

subjective methods of, 139

Association,

adjustment as, 52

deterioration and, 999

free,

method of, 216

personality study and, 999

psychoanalysis and, 1138

therapy and, 1138

hysterical disturbances in, 1135

introversion-extraversion and, 1000

principle of,

gravitation, 52

personality traits and, 50

tests, 181

word, 100

Kent-Rosanoff test of, 223, 1000

psychotic responses in, 999

Associative learning, personality in terms

of, 49

Associative reinforcement, 82

A.sthma, psychogenic factors in, 286

Asylum, Bethlem, 1109

Atavism, criminality and, 529, 802

Atrophy, infantile, 634

Attacks,

epileptic, 938

grand mal, 940

Jacksonian, 940

petit mal, 940

psychic equivalent, 941

Attainment level, aspiration level and, 335

Attainment score, 335

Attitudes,

abstract or categorical,

brain lesions and, 1012

conception of, 903

criticism of, 904

schizophrenia and, 892, 895, 902

dependency, 97

family, generalization of, 93

interpersonal and intergroup, 729

measuring, interview method of, 146

public, habit systems and, 57

tests of, 190

Audiogenic attacks, 416 (See "Seizures")

Aura, epileptic, 940

Authority,

balance of love and, 660

parental, patterns of, 659

therapy and, 1116

Autobiography, personality assessment with,

143

Autopsychic, 550

Autosuggestion, 1112

Aviators, anoxia in, 585

B

Babcock test, 979

Baby (See "Infant")

Balinese,

child-mother relationship among, 729

culture of, 94, 728

Basal ganglia, 558

Behavior,

abstract vs. concrete, 902

antisocial, inheritance of, 518

associative learning and, 49

catastrophic, 1010

catatonic, blood acidity and, 593

changes of, gratification amount and, 671

contextual determination of, 73

cooperative and competitive, 105

criminal, theories of, 798

disorders of,

children's, 761 (See also "Childhood,

behavior disorders of")

epileptic, 938

experimental, 389, 413 (See also "Ex-

perimental neurosis")

functional, concept of, 552, 576, 861,

995

organic, 550

psychoneurotic, 833

psychotic, 861

dynamics of,

aspiration level and, 333

clinical approach to, 255

hormone factors in, 609

psychoanalytic, 261, 307

effects of,

classification, 76

definition, 70

multidetermination of, 1170

neurotic (See "Neurosis," "Psychoneu-

rosis," "Behavior, disorders of")

adjustment by, 59

obsessive, harsh infantile training and,

93

periodic, regulation of, 603

physiology of, research difficulties, 582

primary group, 738

profiles of, heredity and, 516

schizophrenic, variability of, 886

sexual, children's, 786

social, hormone factors and, 609

specificity of,

generality and, 40

personality and, 52

trial-and-error, 80

variability of, 80

learning and, 54

Behaviorism, children's disorders and, 769

Beri-beri, 563

Bible, disorders described in, 1107

Bibliotherapy, 1130

bibliography of, 1162

Biochemistry, functional psychoses and,

866

Biotypes, Jaensche's, 20

Birth,

anoxia during, 587, 636

maternal respiration and, 588

psychological significance of, 87

sucking at, 637

trauma of, 87, 700

(Volume II pages 619 to

1220

SUBJECT INDEX

Blindness,

color, inheritance of, 515

night, inheritance of, 515

Blood,

sugar in,

behavior and level of, 589

regulation of, 601

Blood pressure, emotion and, 281

Body,

basic components of, 537

children's manipulations of, 784

dysplasia of, 530

mind and, dichotomy of, 551

psychotic perception of, 990

types of (See also "Constitution," "Phy-

sique")

megalosplanchnic and microsplanchnic,

527, 528

Brain (See also "Cerebrum," "Lesion")

anatomical areas of, 566

aplasia of, 564

atrophy of, 560

basal ganglia of, lesions in, 558

concussion of, 557

degeneration of, 562

electrical potentials of, 1033

function in,

levels of, 574

localization of, 565

localization of phylum and, 565

gyri of, malformations in, 564

historical conceptions of, 550

inflammation of, 558

lesions of,

anoxia produced, 587

behavioral variation and, 563

chemical changes and, 558

deficit pattern with, 987

degenerative, 562

developmental, 564

EEC and, 1076

gunshot, 557

personality and, 550

timing and effects of, 561

virus, 561

newborn infants, 628

organ in action, 551

trauma of, symptoms of, 556

tumors of, 554

EEC and, 1068

^Rorschach test and, 556

Brain-stem, motor symptoms and, 551

Breathing, infantile, 630, 635

Bulimia, 273

Cannibalism, 113

Capacity,

abstract or categorical, 892, 895, 902,

903

brain injury and, 1014

functional vs. organic deficit and, 1021

fundamental, definition of, 985

hypnotic improvement in, 474, 478

sensory, hypnotic improvement of, 474,

478

Carbon monoxide, brain pathology from,

587

Cardiovascular disturbances, 280

Case study,

personality appraisal by, 160

points of view on, 162

quantification of, 165

reliability of, 164

scientific, 161

short contact, 163

uses of, 165

validity of, 165

Castration,

behavior after, 607

complex, 111, 121

fear of loss of love as^ 88

Cat, experimental neurosis in, 405

Catastrophic reactions, 386

Catharsis, definition, 1135

Cathexis, establishing maternal, 631

Cerea, flexibilitas, treatment adequacy and

incidence of, 895

Cerebrotonia, 544

Cerebrum,

arteriosclerosis of, 562

cortical areas of, 566

developmental abnormalities, 564

frontal lobe function, 865

function,

factor analysis and localization of,

573

general, 555

inhibitory, 555

phylogenetic level and localization of,

565

hemisphere dominance of, 572

hemorrhage of, 558

lesions,

aphasia and, 1011

determinants of effects of, 554

frontal lobe, 556

paretic, 559

senile psychotic, 560

timing and effects of, 560

types of, 554

long circuiting in, delayed reaction and,

574

parieto-occipital area of, 572

parieto-temporal area, 571

prefrontal areas of, 567

trauma of, 556

tumor of,

EEC and, 1068

Rorshach test and, 556

Character,

definitions of, 7

neurotic, 840, 931

ego in, 932

psychopathic personality and, 931

personality and, 7

temperament and, 7

tests of, 174

intercorrelations among, 78

moral knowledge, 174

performance type, 175

Character Education Inquiry, 25

Characterology, literary,

Jean de la Bruyere, 13

Theophrastus, 12

Chemogenic, 552

Chicago,

area rates of psychosis in, 750

delinquency areas in, 742

(Volume 1 pages 1 to 618)

SUBJECT INDEX

1221

Childhood,

behavior disorders of, 761

classification of, 765

complaint factor, 763

constitutional factor in, 776

definition of, 761

EEC in, 1085

emotional factor in, 771

fusion of factors in, 776

intelligence and, 770

manifestations, 777

motivation, 769

physical factors in, 769

situational factors in, 773

therapeutic principles, 788

changes of behavior in, 670

development in,

experience and, 652

super-ego and, 653

differences in flexibility in, 672

disorders of,

attack, 786

behavior, 761

interpretations of monopolistic, 767

interpretations of pluralistic, 769

sexual, 785

EEC in, 1053

emotional disorders of, 782

enuresis in, 780

epilepsy in, 786

experience of self, 666

frustration reactions in, 671

latency period of, 679

part-dysfunctions of, 780

preschool period of,

locomotion in, 657

maturation and socialization, 657

psychoses in, 787

psychosomatic disorders in, 781

resistance in, 762

sex differences in behavior during, 674

sex interest in, 679, 695

sexual behavior in, 785

studies of, interests directing, 652

therapy in, 788

verbal disorders of, 783

whole-dysfunctions of, 781

Children,

affect hunger in, 1177

brain damage in,

irreversible, 777

transitory, 779

examination of, play technique in, 772

parental control of, ecology and, 744

"problem," 681

protective methods with* 772

psychiatric therapy of, 1147

psychoanalysis of, 1149

sex life of, 686

treatment of,

culture and, 93

effects of unresponsive, 633

spoiling and responsive, 90

Choice,

aspiration level as, 356

conflict in, 439

time of and similarity in, 455

types of conflict in, 442

Chorea, Huntington's, 506

heredity of, 521

Circulation,

emotional disturbances and, 280

fetal, 628, 630

Clairvoyance, hypnotic, 474

Cleverness, statistical factor c, 39

Clinic,

habit, 1167

child guidance, 1183

Clubs, boys, 1189

Cold, emotional factors in common, 289

Colitis, emotion and, 278

Communism, American, displacement and,

60

Competition, 105

aggression and, 116

determinants of, 105

socialization and, 105

Complexes,

castration, 653

frustration tolerance and, 386

hypnotically induced, 481

indicators in word association, 225

Oedipus, 653

Compulsions, 852

act-habits as, 56

Concussion, brain, 556

Condition, paranoid, 907, 909

Conditioning,

acquisition process in, 395

domestication in, 392

experimental neurosis and, 389

learning and, 83

method of, 392

monotony in, 392

Pavlov frame, 391

pig, 397

principles of, in learning, 80

psychosis and, 1005

reinforcing agents in, 392

relationship between animal and experi-

menter in, 393

traumatic factors in, 397

Conduct, disorders of, 826

Conference on interview, 144

Confidence, level of, 335

Conflict, 431

adjustment and, 72

anxiety and, 451

approach-approach, 442

approach-avoidance, 446

aspiration level and, 356

audiogenic seizures and, 426

avoidance-avoidance, 442

complex habit, 459

compromise responses in, 461

culture and, 72

discrimination, 452

dynamics of, 431

dynamogenesis and, 460

experimental studies of, 431

factors inducing, 448

gradients in, 434

habit interference and, 459

hypnotic induction of, 481

incompatibility in, types of, 456

internal obstacles and, 382

leaving field, 443

negative transfer and, 459

principle of, 72

reactions in types of, 451

(Volume II pages 619 to 1191}

1222

SUBJECT INDEX

Conflict Continued

reactions to, rat's, 413

reward and, 80

spread of, 462

subculture, minority groups and, 681

theoretical assumptions, 433

theory of, stimulus-response, 437

types of, 432

typical situations of, 264

vacillation in, 437

Conscience, 110, 111, 653, 822

Consciousness, 550, 857

Constipation, 279, 642

Constitution,

anthropometric quantification of, 529

children's disorders and, 776

crime and, 534

definitions of, 927

differences of, childhood development, 662

experiences of self and, 666

functional psychoses and, 863

Gall's work, 527

interests and, 653

Kretschmer's types of, 530

morphological index and, 528

physique and temperament, 544

present-day problem of, 537

psychology and,

American and British research, 531

Beneke's contribution, 529

French contribution, 527

German contribution, 529

Italian contribution, 528

psychopathic, criteria of, 827

temperament and, history of, 526

types of,

clinical symptoms and, 534

disease and, 530

megalosplanchnic, 528

microsplanchnic, 528

psychopathologic, 842

psychosis and, 533

Constitution Clinic, 535

Constitutional factors in personality, 526

Constitutional psychopathic inferior, 922

interpretations of, 931

symptoms of, 924

Context, behavioral, 73, 654

emotional, 257

Control, constructive conscious, 1121

primary, 1121

Convulsion,

audiogenic, in rat, 414

epileptic, 940

metrazol, 588

Cooperation, 105

migration effects on, 738

tests of, 176

Cooperativeness,

determinants of, 105

intelligence testing and, 975

Coordination, community, programs for,

1185

Copulation, hormonal vs. neural factors in,

603

Correlation, heredity and, 509

Cortex,

cerebral (See also "Brain," "Cerebrum")

areas of, 556

multiple sclerosis of, 778

Covariance, analysis of, heredity and, 509

Cretinism, endocrine factors in, 603

Crime,

conflict and, 811

definition, 795

ecological factors in, 740

motivation of, 805, 809

conflict in, 814

family factors in the, 816

frustration in, 816

group identification and, 816

prevention of, 1184

psychopathic personality and, 810

psychosexual development and, 818

theories of, 798

Criminal personalities, 794

Criminality,

behavior dynamics of, 804

ego in, 932

heredity and, 803

rates of,

rural-urban, 740

urban ecology and, 741

stigmata of, 802

nonexistence of, 803

super-ego and, 813

Criminals,

affect poverty in, 810

anatomical characteristics of, 801

atavism in, 529, 802

delinquents and, definitions, 795

epilepsy among, 809

feeblemindedness among, 805

intelligence of, 806

neuroses among, 809

personal characteristics of, 818

psychoses among, 805

Crying,

effort and control of, 89

fixation of, 89

Cue, learning and, 82

Culture,

adolescent instability and, 720

ambivalence and, 72

American, child training in, 98

Appollonian vs. Dionysian, 720

Balinese, 94

calendar in, 730

child treatment and, 93

conflict and, 72

description of, psychiatric concepts in, 721

ecology and, 736

emotional intensity and, 720

habit-systems and, 57

heterogeneity and standardization in, 723

historical approach to, 716

infantile learning and, 93

interdependence of behavior patterns in,

introversion-extraversion in, 720

learning and, 732

migration effects on, 737

Mohave, 115

Navaho, 95

organismic approach to, 717

organization within, 715

personality and, 714

Plains Indians', 721

psychoanalysis and, 724

relativity of abnormality in, 721

(Volume I pages 1 to 618)

SUBJECT INDEX

1223

Culture Con tinned

Tennessee hill-country, 655

typological approach to, 721

configurational argument for, 723

uniformity of personality in, 727

variations in,

child experience, 724

goal orientation, 731

interpersonal behavior, 732

world view, 730

Zuni, 721

"Culture area," 716

Cycles, manic-depressive, 885

Cyclothyme, schizothyme and, 19, 21

D

Deafness, tone, inheritance of, 515

Defense,

mechanism of (See "Dynamisms")

psychobiological levels of, 379

Deficit, psychological,

association experiments and, 999

definition of, 971

deterioration and, 971

emotion and, 1001

epileptic, 952

factor analysis of, 988

language (aphasia), 1008

measuring,

Babcock method for, 979

baselines for, 972

mental age, 973

methods of, 972

memory, 1006

mental age,

frontal lobectomy and, 977

psychoses and, 973

nature of, 1020

reaction complexity and, 996

reaction time and, 993

receptive processes and, 990

reflex latency and, 995

schizophrenic and senile, 899

specific types of, 989

tests of, intelligence, 972

Degenerate, criminal as a, 802

Degeneration, stigmata of, 802, 823

Delinquency (See also "Criminality/

"Crime")

abnormality and, 797

adolescent, incidence of, 702

areas of, 742

crime and, definitions, 795

feeblemindedness and, 808

life experience and, 677

prevention of, programs for, 1185

psychoanalytic treatment of, 1149

rates of, ecology and, 741

tradition of, 745

Delinquents,

personality of, 794, 812

psychoanalytic studies of, 809

Delusions,

schizophrenic, 890

somatic, 991

Dementia,

definition, 971

epileptic, 953

Dementia Continued

schizophrenic, 896

senile, 560

Dementia paralytica, 559

Dementia praecox (See also "Schizophre-

nia")

history, 887

inheritance of, 520

section on, 887

Demoniacal possession, 798

Dependence, oyerprotection and, 681

Depersonalization, schizophrenic, 991

Depravity, insanity and, 822

Depression (See also "Manic-depressive

psychosis," "Melancholia")

agitated (anxious), 882

fatigue-effect reversals in, 998

history of concept, 878

Kraepelinian varieties of, 879

retarded, 880

statistical factors and, 39

Deterioration,

definition of, 971

emotion and, 1001

epileptic, 953

"g,'\ 981

habit, schizophrenic, 896

intelligence tests of, 972

measures of,

Babcock method, 979

baselines for, 972

mental age, 973

practice improvement and, 1004

schizophrenic,

regression and, 899

senile and, 899

test results and, 898

variability and, 1004

Determinism, cultural,

adolescent instability and, 720

conception of, 714, 715

emotional intensity and, 720

Development (See also "Growth")

adolescent,

experience and, 691

Freudian theory, 696

parental interference and, 706

childhood,

constitutional differences and, 662

experience and, 652

frustration and, 671

interpersonal relationships and, 653

longitudinal studies of, 664

consistency after six years, 677

dynamics of, 842

emotional, direction of, 646

environment and, 843

imaginal, 675

infantile,

affectional experience and, 643

anal stage of, 624

anoxia and, 635

mothering and, 633

oral experience and, 635, 638

oral stage of, 624

psychoanalytic theory of, 622

sucking restriction and, 639

toilet training and, 640

weaning and, 640

new function with, 653

(Volume II pages 619 to 1191)

1224

SUBJECT INDEX

Development Con tinued

organism-environment field and, 653

prenatal, 622

psychosexual theory of, 622

spurts of, sensitivities with, 665

Deviance, cultural, 722

Devil, possessed with, 1108

Diabetes, behavior effects of, 590

Diagnosis,

brain tumor,

EEC in, 1044, 1068

Rorschach test in, 556

personality,

artistic expression in, 244

attitude scales in, 190

case records in, 163

character tests in, 174 ^

drawing and painting in, 243

interest-value tests in, 190

objective tests in, 170

play technique in, 239

projective methods in, 214

rating methods in, 150

temperament tests in, 179

thematic apperception test in, 235

word-association in, 223

sociometric, 158

Diet,

behavior and vitamin, 597

behavior effects of, 595

Dilantin, epilepsy therapy and, 949

Discipline,

dependency and, 101

individual reactions to, 662

love and, 101

balance of, 660

punishment in, 101

Discrepancy score,

definition, 335

generality of, 347

realism and, 372

reference frames and, 371

trait correlates of, 351

variability of, 353

Discrepancy, vocabulary vs. mental age,

982

Discrimination, conflict in, 452

generalization and, 454

Disease,

conceptions of,

astrological, 1107, 1109

Hippocratean, 1108

habit-effects from, 593

mental (See also "Disorders, mental,"

"Disorders, neuropsychiatric," "Dis-

orders, behavior," "Psychoneuroses,"

"Psychoses")

concepts of functional, 552, 576, 861,

995

ecology of, 738, 747

neurological approach to, 547

prevention of, 1164

social organization and, 752

Tay-Sachs, 777

venereal disease, urban ecology and, 751

Disorders,

affective, 873

attack, 939

behavior, children's, 761

brain damage and, 777

Disorders Continued

behavior, children's Continued

classification of, 765

dynamic, 552

complaint factor in, 763

EEC in, 1085

motivation and, 767

parent-child relationships and, 703

chemogenic, 552

conduct, 826

constitutional development and, 922

endocrine, EEG in, 1080

genogenic, 552

histogenic, 552

mental (See also "Disorders, behavior,"

and "Disease, mental")

adolescence and, 701

ecological factor in, 738, 747

migration and, 738

neurological approach to, 547

prevention of, 1164

rates of, ecological variations in, 730,

740

neuropsychiatric, vitamin deficiency and,

563

personality,

multidetermination of, 1170

prevention of, 1164

psychogenic, 552

sexual, children's, 785

theory of, psychoanalytic, 1137

Disorganization, social,

mental disorder and, 752

mobility and, 738

Displacement, 263, 317, 461

Dissociation, 1109

abreaction and, 1111

Zuni culture and, 721

"Distributive analysis and synthesis," 1126

Dobuans, paranoia in culture of, 722

Dog, conditioning in, 389

experimental neurosis in, 390, 403

Dominance, cerebral,

inheritance of, 514

nature of, 572

Drawing, diagnostic uses of, 243, 992

Dreams, 218

analysis, 588

content of, 221

emotional stress in, 222

Freud's theory of, 219

functions of, 222

interpretation of, 1136

summary on, 223

symbols in, 221

Drive,

habit adjustment and, 59

instinctual,

Freudian libido and, 623

pleasure and, 623

reduction of, reward as, 79

Drugs,

EEG and, 1065

psychiatric use of, 1122

Dynamics of behavior, clinical approach to,

255

Dynamisms,

conversion, 848

displacement, 263, 317

fixation, 307

(Volume I pages 1 to 618)

SUBJECT INDEX

1225

Dynamisms Continued

intrajection, 263

projection, 324

rationalization, 375

reaction-formation, 439

regression, 311

repression, 123, 262, 321

resistance, 328

sublimation, 320

substitution, 319

Dynamogenesis, 460

Dyskinesis, 849

Dysplasia, 530

Dysrhythmia, cerebral, 1070

epilepsy and, 958

E

Eating, emotional disturbances of, 273

Ecology, human,

concept of, 736

delinquency rates and, 741

migration and, 737

organized vice and, 746

psychosis rates and, 747

suicide rates and, 747

symbiosis in, 736

theory of effects of, 738

Ectomorphy, 540

Education, therapy and, 85

EEG,

anesthesia and, 1065

anoxia, 1062

attention and, 1057

blood sugar level and, 1064

blood sugar reduction and, 590

brain lesions and, 1076

clinical uses of, 1044

developmental aspects of, 1053

effort and, 1057

emotion and, 1058

endocrine disorders and, 1080

epilepsy and, 1072

frequency components of, 1038

hypnosis and, 1060

infectious conditions and, 1079

inheritance of, 521

intelligence and, 1061

migraine and, 1075

neurological application of, 1068

normal individual differences in, 1045

personality and, 1049

pH and, 1064

physiological requirements, 1062

sensory stimulation and, 1054

temperature and, 1064

Efficiency,

index of,

Babcock, 979

psychosis and Babcock, 979

schizophrenic, 898

loss of, measuring, 972

Effort, EEG and, 1057

Ego, 653, 697

weakness of, 385

Ego-ideal, frontal lobes and, 864

Electrical activity, cerebral, 418, 1033

Electrodes, electroencephalography and,

1042

Electroencephalogram (See "EEG")

Electroencephalography, 1033

amplifiers used in, 1044

history of, 1033

methodology in, 1042

phenomena of, 1035

recording systems in, 1043

Electrograms, variety of, 1038

Electro-shock, therapeutic, 1124

statistical results of, 1152

Elimination,

disorders of, 278

infant experience of, 640

learning control of, 91

psychology of, 277

Emotion,

children's disorders and, 771

children's, play investigation of, 772

circulatory effects of, 280, 284

colitis and, 278

cultural determination of, 720

EEG and, 1058

elimination and, 277

endocrine factors in, 606

enuresis and, 293

epilepsy and, 292, 946

experimental neurosis and, 407

gastrointestinal function and, 272

headache and, 292

heart disorders and, 280

hypertension and, 281

infantile outbursts of, 643

physiological effects of, 269 (See also

"Psychosomatic medicine")

methods of investigation, 271

specific correlations, 272

resistance and, 328

respiratory disturbances and, 286

skin disorders from, 289

word-association and, 275

Encephalitis, 559

behavior effects of, 593

child and adult effects of, 561

EEG in, 1080

lethargic, 561

syphilitic, 559

virus, 559

Encephalitis lethargica, 561

Encopresis, 781

Endocrines (See also "Homeostasis")

behavior and, 600

emotional behavior and, 606

functional psychoses and, 866

intellectual behavior and, 603

mating and, 603

periodic behavior and, 603

Endocrinopathies, children, 779

Endomorphy, definition, 540

Energy, psychic, 385, 463

Enuresis, 780

emotional, 293

Environment, 71, 654, 660

therapeutic manipulation of, 1146

Epilepsy,

altering seizures in, 947

aura, 940

behavior disorders in, 953

brain waves in, 942

cortical dysrhythmia, 958

definition, 938

deterioration in, 953

(Volume 11 pages 619 to

1226

SUBJECT INDEX

Epilepsy Continued

diagnosis of, 947

EEC in, 942, 1069

emotion and, 946

grand mal, 940

history, 939

hostile impulses in, 292

incidence of, 939

inheritance of, 521, 946

Jacksonian attacks of, 940

mechanisms of, 941

migraine and, 950

myaclonus, inheritance of, 521

noise-induced in rat, 414

personality in, 953

petit mal, 940

pharmacology and, 949

prophylaxis in, 948

public education about, 950

responsibility of public, 949

Rorschach test and, 961

social adjustment in, 954

structural abnormalities and, 946

symptoms, 939

treatment of, 948

Epinephrine, behavior after injections of, 589

blood sugar regulation and, 601

Equilibrium, dynamics of, 431

Ergazia, concept of, 1126

Ergotamine tartrate, migraine and, 951

Erogenous zones, survival and, 118

Esophagous, nervous disorders of, 275

Essential hypertension, hostility in, 281

Estrone, 608

Etiology, i

preventive effort and, 1169

types of, 552

Eugenics, prevention of disorder and, 1174

Evaluation,

methods of subjective, 139

of personality, subjective, 139

Excitability,

alkalinity and, 591

newborn differences in, 936

Exhibitionism, 785

Exorcism, 1108

Experience,

adolescent,

behavior and, 691

bibliography on, 712

information sources on, 691

personality and, 691

psychological literature, 699

affectional, development and, 643

breathing, infantile, 635

childhood,

anthropological study of, 724

fantasy in, 676

imaginal development and, 675

maturation and, 657

minority groups and, 680

personality development and, 652

vs. infantile, 655

developmental, subculture and, 654

eliminational, 640

expansion of, imagination and, 675

growth, list of, 683

infantile,

age and effects of, 646

animal studies of, 644

Experience Continued

infantile Continued

direct observation of, 627

distance receptors and, 643

endurance of traces of, 645

personality development and, 621

subsequent experience and effects of,

655

weaning as, 640

new,

flexibility of response to, 672

repeating patterns of reaction to, 673

nursery school, 668

oral, infantile development and, 637

social,

individual susceptibilities to, 661

list of, 683

structuring processes in, 670

Experimental neurosis,

aggression in, 403

audiogenic seizure and, 414

cat, 403, 405

conditioned reflex method and, 389

conflict in, 393

discovery of, 389

discrimination conflict in, 455

diurnal activity in, 413

dog, 390, 403

etiology of, 393, 395, 402

generalization of conflict in, 463

manifestations of, 390, 396, 399, 402

monotony and, 396

Nick, Gantt's dog, 404

Pavlov's description of, 390

pig, 399

problem of animal in, 393

rat, 413

self-imposed restraint in, 395

sheep, 394

symptoms in,

cardiovascular, 408

gastrointestinal, 408

neuromuscular, 405

respiratory, 407

sexual, 409

urinary, 408

theoretical considerations, 411

therapy in, 410

Expression, artistic, 244

Extinction, conditions for, 81

fatigue in, 81

Extratensive, 19, 228

Extraversion (See "Introversion-extraver-

sion")

Factor analysis,

brain localization and, 573

criticism of, 40

factors in personality, 39

logic of, 30

nature of factors, 33

personality structure and, 28

psychotic test performance and, 988

Spearman's two-factor theory of, 30

Failure,

aspiration level and, 343, 373

selective test in psychosis. 984

Fainting, 947

(Volume I pages 1 to 618)

SUBJECT INDEX

1227

Family,

attitudes from generalization of, 93

emancipation from, 127

interpersonal relations in, 656

personality formation in, 109

Fantasy,

children's, 675

schizophrenic, 890

Fatigue,

anoxia, 586

extinction and, 586

Feeblemindedness,

anoxia at birth and, 588

EEG and, 1052, 1086

inheritance of, 506

neurology and, 565

Feeding,

infancy and, 91

infantile frustration of, effects on adult,

Fetus, EEG in a, 1054

Fever, EEG and, 1064

EEG in a, 1054

learning in a, 87

Field,

child-in-total-, 654

leaving, 443

organism-environment, 653

theory, criticism of, 73

Figures,

ambiguous, manic-depressive psychosis

and, 994

Wertheimer's, 990, 992

Fixation, 264, 623

emotional reinforcement and, 60

experiments on, 308

instrumental act, 308

stimulus-response theory of, 308

Flatterer, Theophrastus', 12

Flexibility, waxy, 895

Fluency, statistical factor f, 39, 988

Food,

excessive intake and behavior, 596

selection of, homeostasis and, 602

Forgetting, unpleasantness and, 321

Formulation, symbolic, aphasia as, 1009

Friendliness, experience producing, 673

Frohlich's syndrome, 779

Frustration,

definition of, 380

direction of reaction to, 384

ego-defensive reactions and, 383

extrapunitive reactions to, 383

impunitiye reactions, 383

intrapunitive reactions, 383

need-persistive reactions to, 383

obstacles classified, 382

patterns of gratification and, 657

primary, 280

reactions to,

catastrophic, 386

childhood forms of, 670

infant differences in, 664

types of, 383

regression and, 314

secondary, 280

stress situation and, 380

symbolic processes and, 386

tension and, 380

theory of, 379

therapy and, 387

Frustration Continued

tolerance, 385

complexes and, 386

early experience and, 387

symbolic processes in, 386

therapy and, 387

Function, nervous,

anoxia and, 585

lobotomy and, 551

Functional autonomy, instance illustrative

of, 55

Functional, definitions, 551, 552, 576, 861,

995

Functionalism, adjustment and, 71

Ganglia, basal, behavior and lesions in, 558

Gastritis,

anoxia and, 586

emotion and, 273

Gastrointestinal disturbances, 273

General paralytica, senile psychosis and,

560

Generalization,

family attitudes, 107

principle of, 452

Genes, linkage of, 511

Genetics (See "Heredity")

Genito-urinary function, emotional effects

on, 292

Genogenic, 552

Gestures, 146

Goal, defined, 56

Goat, conditioning , in, 391

experimental neurosis, 391

Gonads, behavior and castration, 607

Gradients,

approach vs. avoidance, 449

conflict and, 433, 440

generalization, 452

temporal and spatial, 441

Grand mal, 940

dilantin and, 949

EEG in, 942

Gratification, frustration and, patterns of,

657

Group status, 158 (See also "Popularity")

personal preference method, 158

sociometry, 158

stability of, 159

Groups, minority, childhood experience in,

680

Growth (See also "Development")

patterns of, 666

spurts of, sensitivities created by, 665

Grundfunktion, 562

Guidance, child, 1177

Guilt, time of punishment and, 111

Gyri, malformations of, 564

H

Habit,

acquired drives as, 56

acquisition of, principle of association

and, 53

(Volume II pages 619 to 1191)

1228

SUBJECT INDEX

Habit Continued

acts as, 55

adjustment and, 58

conflict of, 431

facilitation of, 460

fixation of, 264

interference of, 459 (See also "Conflict")

movement and, 51

movement-habits, 54

persistence of, 61

fatigue and, 53

personality traits as, 50, 54

progression of, socialization and, 102

regression of, 311

reinforcement of, emotional, 60

repetitiousness of response as, 54

systems of, 57

basis in culture, 57

Habit-acts, 55

Habitus (See also "Body," "Constitution,"

"Physique")

apoplecticus, 526, 528

types of,

Hippocrates, 526

phthisic, 526, 528

Haemophilia, inheritance of, 506, 515

Hallucinations, incidence of, 991

schizophrenic, 890

Halo effects,. 152

Handedriess, inheritance of, 514

Hay fever, psychogenic factors in, 289

Headache,

emotional factors in, 292

migraine, EEC in, 1075

Hearing, deprivation of, inheritance of, 514

Heart,

disorder of, anxiety and, 584

disturbances of,

emotional, 280, 584 ^

experimental neurosis and, 408

soldier's, 584

Hebephrenia,

history, 887

schizophrenic, 894

Hemorrhage, cerebral, emotion factors in,

284

Heredity, 505

animal experiments on, 507

audiogenic seizures in rat and, 422

correlation technique and, 509

pedigree approach and, 510

covariance and, 509

cretinism, 519

crime and, 803

dementia praecox and, 520

economic status and, 518

epilepsy and, 946

feeblemindedness, 506

functional psychoses and, 862

graded characters and, 506

history of human, 505

Huntington's chorea, 506, 521

linkage of genes in, 511

manic-depressive insanity and, 520

maze ability and, 507

Mendel ism, 506

methodology,

animal studies, 507

human studies, 508

mongolism and, 521

Heredity Con tinuea

pedigree method, weakness in, 513

personality and, general aspects of, 516

prenatal influence and, 507

profiles of behavior and, 516

psychoneurosis and, 519

race differences and, 517

schizophrenia and, 520

selective mating and, 510

sex perversion and, 519

special skills and, 513

specific traits and, 511

temperament and, 521

variance analysis and, 507

Heterosexuality, adolescence and, 693

Histogenic, 552

Homeostasis, 601

organismic responses and, 602

Honesty, tests of, 175

Hope, therapy and, 1134

Hormones,

behavior and, 601

gonadal administration of, behavior and,

607

gonadatropic and ovulation, 601

mating and, 603

periodic behavior and, 603

sex,

adolescent interests and, 694

social behavior and, 609

therapeutic use of, 1153

Hospitals, statistics on U, S., 1150

Hunger,

affect, 655

children's disorders and, 774

behavior effects of, 596

Huntington's chorea, 506

inheritance of, 521

Hydrocephalics, 564

Hygiene, mental,

definition, 1164

focusing effort in, 1169

physiology and, 1175

principles of prevention in, 1169, 1173

social control in, 1180

types of, 1165

Hypalgesia, 848

Hyperglycemia,

diabetic behavior, 590

EEC in, 1064

immediate effects of, 589

Hypermnesia, hypnotic, 478

Hypersensitivity, statistical factor of, 39

Hypersynchrony, 1070

Hyperventilation,

anxiety and, 592

behavior effects of, 592

Hypnoanalysis, 490

Hypnosis,

anesthesia in, 476, 478

anesthetic uses of, 473

antisocial uses, 488

crime in, 485, 488

criteria of, 469

dangers in, misinterpretation, 486

definition, 466

EEC in, 1060

harmful suggestions in, 487

hypermnesia in, 478

modern conception of, 475

(yolume I pages 1 to 618)

SUBJECT INDEX

1229

Hypnosis^ Continued

moods induced in, 480

nature of,

early theories of, 491

goal -directed behavior, 492

psychoanalytic theory of, 491

regression, 491

suggestion and, 496

negative afterimages in, from visual

hallucinations, 477

neurotic attitudes produced in, 489

phenomena of, historical, 474

psychopathology of everyday life in, 480

sleep and, 478

subject's control in, 483

suggestibility and, 475

uses of,

experimental, 479

therapeutic, 473, 490, 1110

Hypnotism, 466

definition, 466

history of, 472

technique of hypnotizing, 467

Hypnotist, definition, 466

Hypnotizability,

deference and, 472

factors which contribute to, 495

incidence of, 470

individual differences in, 470

motivation and, 472

personality traits related to, 471

Hypnotizing, 467

suggestions in, 468

Hypoglycemia, effects of, 589

Hypomania, 876

Hypothalamus, emotion and, 576

Hypothyroidism, cretinism, 603

metabolism in, 604

Hysteria, 848

brain waves in, 947

conceptions of, Galen's, 1108

conversion in, 848

dynamics of ideas in, 1135

EEG in, 1084

fumigation against, 1107

inheritance of, 519

organic pathology in, 849

pseudo-psychotic symptoms, 850

latmul, 107

mother-child relationship among, 729

Identification, 109

socialization and, 125

Idiocy,

amaurotic, 777

inheritance of, 522

Illness, physical, behavior sequels of, 777

Imagination, expanding, experience and,

675

Imaginative productions, interpretation of,

214

Imbecile, moral, 799, 824

nonexistence of, 801

Imbecility, inheritance of, 522

Imitation, socialization and, 108, 125

Immunology, 535

Impulse, Tricb and, 72 (note)

Incompatibility, response, types of, 456

Index,

alpha, 1044

efficiency, 896

schizophrenic and, 898

set, 994

Individual, delinquent, 812

Inertia,

dichotomous typologies and, 17

perseveration and, 17

Infancy,

anxiety in, evidences of, 628

bad habits in, 91

bladder control in, 91

brain development in, 628

constipation in, 642

crying in,

effort and, 89

fixation of, 89

dependency attitudes in, 97

discipline in, 91

early,

birth trauma and, 87

oxygen need in, 630

personality development in, 87

EEG in, 1053

experience during, personality, 622, 645

later, 91

marasmus in, 634

maternal cathexis in, 631

morality in, 93

need for contact in, 628

oral experience in, 637

patterning of behavior in, 621

pleasure strivings of,

fixation of, 623

neurosis and, 622

sex perversions and, 622

psychosexual stages of, 623

punishment in, 91

responsive treatment and learning in,

88

satisfaction in, 88

kinesthetic, 631

schedules of care in, criticism, 89

socialization in, 85

tensional states of, 628

Infant,

attachment to mother, factors in, 631

mother's relationship to, 631

newborn,

brain in, 629

characteristics of,

behavioral, 629

physiological, 629

psychological, 628

circulation in brain of, 628

feeling need in, 630

sucking in, 628

rules for handling, 86, 91, 647

Infection, focal, functional psychosis and,

865

Inferiority,

constitutional psychopathic, 826, 923

crime and, 801

inheritance of, 928

organ, children's disorders and, 770

Inflammation, brain, 558

Inheritance (See "Heredity")

Inhibition, retroactive, generalization in,

455

(Volume llpoges 619 to 1191)

1230

SUBJECT INDEX

Initiative,

sexual, cultural variations in, 726

tests of, 184

Injury,

birth,

anoxia and, 587

maternal respiration and, 588

brain.

abstract ability and, 386, 1115

aphasia and, 1011

Ink blots, interpretation of (See "Ror-

schach test")

Insanity,

constitutional, 823

moral, 799

Instinct, Trieb and, 72

Institutions, social, ecology and, 741

Insulin,

blood sugar regulation and, 601

injections of and learning, 589

psychiatric use of, 1123

Integration,

adjustment and, 74

principle of, 73

Intelligence,

adolescent conflicts and, 699

adopted vs. unadopted sibling, 513

anoxia and, 586

criminal, 806

EEG and, 1061

inheritance of, 511

normal adult, 973

parent-child resemblance in, 512

quotient, 173, 771, 781

tests of (See "Tests, intelligence")

twin differences in, 512

Interests, 190 ; sex hormones and, 694

Interpretation, psychoanalytic, 256, 726

Interview, conference method of, 144

framed, 147

group, 149

improvement of, 145 ^

personality appraisal in, 144

psychoanalytic, 327

Introjection, 263

Introversion-extraversion,

hypnotizability and, 471

hysteria vs. psychasthenia and, 17

morphological types and, 17

schizophrenia vs. mania and, 17

IQ, 173, 771, 781

Irritability, anoxia and, 587

Jaensches biotypes, 20

Judgment, anoxia and, 585

Jurisprudence, medical, 799

K

Katzen jammer Kids, 101

Kinship, systems of, 718

Korsakoff's syndrome, memory in, 1008

Language,

adjustment and, 84

aphasic disorders of, 573, 1009

LanguageContinued

brain injury and, 572

learning and, 84

Laryngitis, emotional factors in, 289

Latency period,

imagination in, 127

psychoanalysis and, 127

sex-repression in, 125, 126

Latency, reflex, psychosis and, 995

Laughter, child differences in, 664

Law, criminal, habitual, 823

Leadership,

appraisal of, 147

assessment of, 149

Learning,

animal experiment and, 99

anticipatory responses in, 83

associative,

adjustment as, 52

personality and, 49

personality traits and, 50, 62

reinforcement in, 53

childhood experience and, 670

cues in, 82

discrimination in, 81

extinction and, 81

fatigue in, 81

fetal, 87

generalization in, 81

higher order, conditioning as, 83

language and, 84

psychosomatic patterns and, 671

punishment in, 80

reinforcement in,

association as, 53

associative, 82

conflict and, 80

gradient of, 80

reward and punishment as, 80

stimulation reduction as, 79

time of reward and, 80

socialization and, 85

theory of,

anthropology and, 85

reward, 78

trial-and-error, 670

variability of response in, 54

Lesions,

brain,

EEG and, 1076

timing and effects of, 561

types of pathology in, 554

cerebral, factors in effects of, 554

Level of aspiration (See "Aspiration

level")

Level, phylogenetic, cerebral localization

and, 565

Libido, 117

conception of, 623

Life history,

adolescent period in, 128, 691

critical stages in, 122, 847

economic struggle and, 131

infancy in,

early months of, 86

late, 91

latent period in, 127

marriage in, 130

maturity in, 131

parenthood period in, 130

(Volume I pages 1 to 618)

SUBJECT INDEX

1231

Life history Continued

reconstruction of, psychoanalytic, 260

vocational adjustment in, 130

Lobectomy, frontal,

deficit following, 568, 977, 1013

psychosis and, 569

Lobotomy, pref rental,

deficit following, 571, 1125

therapeutic statistics of, 1153

Localization, cerebral, 565

Locomotion, preschool child's, 657

Logic, schizophrenic, 902

Love, balancing discipline and, 101, 660

Lunacy, moral, 822

M

Magic, therapy by, 1107

Magnetism, animal, 1109

Maladjustment,

adolescent,

culture conflict and, 704

home conflicts and, 703

children's,

affect hunger and, 774

anxiety in, 762

complaint factor in, 763

constitutional factor in, 776

emotional factor in, 771, 782

intelligence and, 769

parent-child relationship and, 774

physical factors and, 769

resistance and, 762

situational factor in, 773

migration and, 738

prevention of, programs for, 1184

recurrent, psychopathic personality and,

924

epileptic, 954

psychopathy and, 932

sociopathic, 931

Malingering, psychoneurosis and, 857

Mania,

acute, 876

definitions, 875

forms of, 875

hyperacute, 878

subacute, 876

thyroid function in, 606

Manic-depressive psychosis,

absence of rate pattern for, 751

cycles in, 885

depressed phases, 878

ecology and, 751

EEG in, 1081

fatigue reversals in, 998

fluctuation of perspective in, 991

history of, 873

inheritance of, 520

manic phase of, 875

neurology and, 577

present conception of, 874

question of unity of, 886

Mannerisms, schizophrenic, 891

Manus, family pattern among the, 107

Marasmus, 634

Marriage, infantile sexuality and, 119

Masochism, female, 121

Masturbation, 116, 785

adolescence and, 694

Matching method, personality and, 42

Maturation,

preschool period and, 657

toilet training and, 641

weaning and, 640

Maze, socialization and, 99

Maze-test, 183

Mechanisms, psychoanalytic (See "Dyna-

misms")

Medulla, motor symptoms and, 551

Melancholia (See also "Depression"), 878

history of concept, 878

involutional, 883

Memory,

anoxia and, 587

feeling tone in, 321

hypnotic improvement of, 474, 478

psychotic deficit in, 1006

repression and, 321

retention and impression, 1007

Menarch (See also "Adolescence" and "Pu-

berty")

interest changes at the, 682, 694

Meningitis, 559

Mental age, deficit in terms of, 973

Mesmerism, 1110

Mesomorphy, 540

Metabolism,

cretinism and, 604

homeostasis and, 601

thyroid and, 604

Metrazol,

cerebral anoxia and, 588

therapeutic statistics and, 1152

therapeutic use of, 1123

Migraine,

EEG in, 1075

description of, 950

epilepsy and, 950

personality and, 963

therapy for, ergotamine tartrate, 951

Migrants, personality of, 737

Migration,

competition and, 737

cultural effects of, 737

social cooperation and, 738

Military psychology, German, 149

Military service, unfit personalities in the.

822

Military training, personality and success

in, 199

Mind-body relationship, 270

Minneapolis, suicide districts in, 748

Mobility, culture and, 737

Mongolism, inheritance of, 521

Monomanias, 801

Moods, hypnotically produced, 480

Moral knowledge, tests of, 174

Morphological index, 528

Morphology,

basic body components, 538

types of, 527

Mother, establishing attachment for, 631

Mothering,

inadequate, 646

negativism and, 633

regression and, 633

inconsistency of, 646

(.Volume II pages 619 to

1232

SUBJECT INDEX

Motivation,

animal experimentation and, 99

derived, theory of, 83

emotion as, 83

frustration as, 381

goal, 56

habit as, 55

learning theory and, 79

monopolistic theories of, 767

Movements, occular, 998

Mundugumor, 727

sexual aggression among, 726

Music ability,

inheritance of, 513

tests of, 198

Mutism,

catatonic, 895

deaf, inheritance of, 515

N

Narcolepsy, 786

Nature, human,

variability vs. universality of, 719

Navaho, passivity of the, 95, 96

Needs,

classification of, 381

growth, mother's personality and, 658

Negativism,

catatonic, 895

children's, 672

infantile, mothering and, 633

Neighborhood, children's disorders and,

775

Neologisms, 894

Nervous system,

behavioral function of, 551

diseases of and behavior, 594

integration of, 551

levels of integration in, 550

physiology and, 584

Neurasthenia, 854

Neuritis, alcoholic, 563

Neuroembryology, 622

Neurology,

brain and mind in, 550

clinical, EEG in, 1068

conditioned reflexes and, 551

lobotomy and, 551

war injuries and, 551

Neurosis (See also "Psychoneurosis")

adjustment in, 59

anxiety, 853

character, psychopathic personality and,

931

cardiovascular, 284

children's, 786

conversion, 848

crime and, 809

esophageal disturbances in, 275

experimental,

activity records in, 394

conditioned reflex method and, 389

discovery of, 389

etiology of, 393, 395, 402

gastrointestinal disturbances in, 408

human and, 405

manifestations of, 402

neuromuscular symptoms of, 405

Neurosis Con tinued

experimental Continued

Pavlov's description of, 390

precipitating maneuvers, 402

respiratory symptoms in, 407

sexual disturbances, 409

spread of conflict in, 463

infantile pleasure strivings and, 622

infantile, reactivation of, 124

inheritance of, 519

problem of choice of, 265

psychoanalytic classes of, 1137

skin, 289

stomach, 275

transference, 1141

Non-representative, test performances, 976

Normal persons,

EEG in, 1045

mental age in, 973

Nosology, children's behavior disorders

and, 765

Nursing,

infantile, development and, 638

initiating, 638

Nutrition,

behavior and, 595

excessive, effects of, 596

intelligence and, 596

motivation and, 596

vitamin, behavior and, 597

Obesity, nutrition vs. energy output in,

597

Occipital lobe, 572

Oedipus complex, 127, 837

cultural variations in, 727

Opinion,

habit systems as, 57

public, polls of, 58

tests of, 190

Organic, functional and, 551

Orientation, goal, cultural variations in,

731

Overeating, emotional factors in, 596

Overprotection, ecology and, 753

Ovulation,

endocrine regulation of, 601

progesterone and, 609

Oxygen,

infantile deficiency in, 630

utilization of, homeostasis and, 601

Paralogical, 901

Paralysis, infantile, 594

Paranoia,

definition of, 907

Dobuan culture and, 722

history, 904

homosexuality and, 326, 905

need for punishment, 905

obsession and, 905

paranoid condition and, 909

projection in, 905

schizophrenic, 895

symptomatology of, 907

(Volume I pages 1 to 618)

SUBJECT INDEX

"33

Paranoid condition, 907

Paresis,

behavior in, 559

EEC in, 1079

efficiency indices in, 980

memory loss in, 559

mental age in, 973

performance in schizophrenia and, 1020

progressions and absurdities in, 1020

Paresthesia, 848

Parietal lobe, 572

Past record, personality in terms of, 66

Pauperism, inheritance of, 518

Payote, Plains Indians' use of, 721

Pecking, need for in chicks, 645

Pediatrics, EEC in, 1034

Pellagra, 563

Penis envy, 121

Peoples, preliterate, behavior disorders in,

722

Peptic ulcer, emotional factors in, 273

Perception,

brain injury and, 991

deficits in, 990

figure-ground, brain injury and, 092

motivationally determined, 324

pattern, brain injury and, 992

projection in, 324

Performance,

representative, 976

test,

psychotic cooperativeness and, 976,

1016

schizophrenic vs. children's, 1017

schizophrenic vs. paretic, 1020

schizophrenic vs. senile, 1019

temperament and adjustment, 180

Persecution, delusions of, 906

Perseveration,

dichotompus typologies and, 17

introversion-extraversion and, 17

statistical factor "p," psychosis and, 988

tests of, 182, 988

Persona, 3

Personalisrnus, 4

Personalistik, 4

Personalitat, 3

Personality,

Apollonian vs. Dionysian, 720

assessment and appraisal of,

application forms in the, 141

case study method of, 160

dream analysis in, 218

free association method in, 216

German military psychology, 149

interview method in, 144

objective test methods of, 170

play technique in, 239

protective methods of, 214

rating scales in, 150

recommendations in, 141

Rorschach test in, 227

subjective vs. objective methods, 139,

140

thematic apperception test, 135

word association test, 223

associative learning and, 49

Balincse, 94

brain lesions and, 553

change of, patterns of, 670

Personality Continued

character and, 7

conceptions of, American vs. German, 6

constitutional factors in, 526

criminal, 794

culture and, 94, 714, 724

definition of, 3, 50, 169, 551, 796

effects of behavior and, 77

habit adjustment, 49

social stimulus value, 74, 75, 140

stable habit systems, 58

delinquent, characteristics of, 794, 818

description of,

adjustment type, 65

literary, 12

social process, 724

development of,

adolescent experience in, 127, 691

childhood experience and, 96, 652

competition and, 105

dynamic theory of the, 68

imitation in, 125

infantile experience and, 86, 621

language in, 104

parental identification in, 125

progression and retrogression of habit

in, 122

t psychoanalytic theory of, 260, 622, 696

disorders of (See also "Childhood, be-

havior disorders of," "Neurosis,"

"Psychoneurosis," "Psychosis")

adolescent, 701

children's, 681, 761

epileptic, 953

sociopathic, 931

dynamic theory of,

anthropology and, 68

clinical approach to, 255

definition of, 68

postulates of, 68

psychoanalysis and, 68

EEG and, 1049

epileptic, 953

evaluation of, subjective, 139

explorations in, childhood events and, 652

factor analysis of, 28

family structure and, 726

habit-adjustment as, 58

habit layers in, 126

hereditary and, 505

history of concept of, 4

inventories of, 186

measurement of (See "Personality, as-

sessment and appraisal of")

migraine and, 963

Navaho, 95

paranoid, 909

prediction from past behavior, 66

preschool child, 668

psychopathic, 922

character neurosis and, 932

concept criticized, 927

crime and, 801

definition of, 923

etiology of, 927

heredity and, 928

history of concept of, 923

moral insanity and, 810

neurotic character and, 810

symptoms and criteria of, 924

(Volume II pages 619 to 1191)

"34

SUBJECT INDEX

Personality Continued

quotient, definition, 173

rating scales of, 150

six-year-old, 677

sociopathic, 931

stroke and, 553

structure of, 3, 10

anthropology and, 720

anti-trait theory of, 25

colorimetrists* analogy and, 10

factor analysis of, 28

habit-systems in, 57

Kahn's theory of, 933

phenomenal appearance and, 10

psychoanalytic theory of, 697

specificity of, 25, 40

statistical factors in, 39

stimulus-response elements in, 25

trait theory of, 40

type of adjustment theory of, 65

temperament and, 8

tests of,

adjustment, 180

application of, 201

attitude, 190

character, 174

classification of, 171

evaluation of, 201

history of, 171

intelligence tests and, 172

interest-value, 190

list of factors in, 199

opinion, 190

personal interests, 192

temperament, 179

theory of,

associative learning, 49

dynamic, 69

trait, 40

type, 11

traits of,

argument against general, 61

aspiration level and, 351, 353

behavioral acts as, 50

dichotomous typologies and, 16

habits as, 54

habit systems as, 61

hypnotizability and, 471

repetitiousness of behavior and, 54

theory of, 40

tripartite psychology and, 10

types of,

anthropology and, 720

dichotomous, 16

psychoanalytic, 623, 642

theory of, 11

Pcrsonlichkeit, 3

Personnel, placement of, 148

Perspective, ambiguous, manic-depressive

psychosis and, 994

Persuasion, 1115

Perversion,

infantile "naughtiness" and, 116

infantile pleasure striving and, 622

sexual, inheritance of, 519

Petit mal, 940

dilantin and, 949

pH, behavior and, 591

Phantasy (See "Fantasy")

Pharmacology, psychiatric, 1122

"Phi" phenomenon, brain injury and the,

991

Phobias, 851

generalization of anxiety in, 463

stimulus-response theory of, 463

Physiology,

adolescent changes in, 692

functional psychoses and, 866

mental hygiene and, 1175

psychological factors and, 583

social factors and, 583

Physiotherapy, 1121

Physique,

character and, 531

components of, 531, 537

ectomorphy, 540

endomorphy, 540

mesomorphy, 540

dimensional concept of, 531

dysplasia of, 530

temperament and, 544

types of, psychosis and, 533

Pick's disease, 562

Pi *'

conditioning in, 397

experimental neurosis in, 399

tantrum in, 397

Pituitary,

deficiency of, learning and, 605

water balance and, 601

Plasmas, pH of body, behavior and, 591

Play, technique of in diagnosis and ther-

apy, 241

Pleasure,

children's motor outlets for, 784

polymorphous, 623

sex and, 623

sucking and swallowing, 624

Pleasure principle, 385

Pneumoencephalogram, 558

Police, crime prevention and, 1187

Poliomyelitis, 594

Popularity (See also "Group status"), 140,

158

personal preference method, 159

sociometry and, 158

stability of, 159

Possession, demoniacal, 1108

Posture,

cultural variations in, 731

schizophrenic, 891

senile posture, 554

Potentials, brain, 1033

PQ, definition, 173

Practice, schizophrenic improvement with,

1004

Pragmatism, 862

Prefrontal lobe, 567

Prejudice, habit systems and, 57

Preliterate, psychosis in the, 722

Pressure, intracranial and symptoms, 557

Prevention,

absolute, 1169

crime, 1184

eugenical, 1174

focusing effort in, 1169

physiological, 1175

presumptive, 1165

principles of, 1173

projects of, 1184

(Volume I pages 1 to 618)

SUBJECT INDEX

"35

Prevention Continued

psychological, 1177

radical, 1168

relative, 1166

substitutive, 1168

therapeutic, 1166

types of method in, 1174

Problems, children's, types of, 766

Processes, receptive, psychotic deficit in, 990

Product-moment, intra-class, heredity and,

509

Progesterone, ovulation and, 6C9

Progressions, arithmetic, schizophrenics vs.

paretics on, 1020

Projection, 263

attribution of traits, 325

clinical studies in paranoia, 327

experiments on, 324

Freud's theory of, 326

ideas of reference as, 326

Project! ve methods, 214

association,

free, 216

word, 223

drawing, 243

dream analysis, 218

painting, 243

play technique, 239

reasons for, 214

Rorschach test, 227

scientific status of, 215

thematic apperception test, 235

verbal summator, 239

Projects, settlement, 1184

Propositionizing, 1009

Proverbs, schizophrenic interpretation of,

1015

Psychasthenia, 851

Psychiatry,

classification in, 870

conditioned reflexes and, 390

dichotomous typologies and, 16

etiology in, 29

medication in, 1122

nosology In, 870

prognosis in, 869

therapeutic methods in, outline of, 1156

therapy in, 1107

Psychoanalysis,

abreaction in, 1135

Adlerian, 1142

adolescent development and, 696

aggression, 315

anthropology and, 71

associative learning and, 64

case illustration of, 257

catharsis in, 1135

children's disorders and, 768

choice of neurosis and, 265

classification of disorders in, 1137

constitutional implications of, 534

cultural relativity and, 725

disorder and typical life history, 264

dynamisms of,

conversion, 848

displacement, 263, 371, 461

fixation, 264, 307

introjection, 263

projection, 263, 324

rationalization, 375

Psychoanalysis Continued

dynamisms of Continued

reaction-formation, 439

regression, 123, 124, 264, 307, 311,

314, 462, 633, 673, 971, 1018

repression, 123, 262, 320, 1136

sublimation, 320

EEC in, 1050

ego functions, 697

emotional context in, 257

endocrine changes and, 608

experimental analysis of phenomena in,

305

experimental psychology and, 265, 329

frame of reference of, limitations in, 337

generalizations from, 261

history of, 1135

infantile stages of development, 622

interpretation in, 256

distortion of, 726

scientific analysis and, 259

interview of, 327

Jungian, 1141

learning and, 71

life history reconstruction in, 260

passive conduct of, 1139

pleasure principle in, 385

psychosexual stages in theory of, 623,

697

reality principle in, 385

resistance in interview, 328

scientific data of, 257

scientific method in, 256

statistics, therapeutic, 1154

substitution and, 263, 319

suggestion in, 1139

super-ego development in, 697

technique of, 1137

terminology of, criticism, 64

theory of, criticism, 64

typical conflict situations in, 264

unconscious and repression in, 1136

Psychobiology , 1125

Psychodynamics (See "Dynamisms," "Con-

flict")

Janet's, 1135

Psychogenesis, conceptions of, 867

Psychogenic, 552

Psychology,

constitutional, history of, 526

medical, neurology and, 577

mental hygiene and, 1177

Psychoneurosis (See also "Neurosis")

anankastic reactions in, 851

anxiety type of, 853

case illustration of, 834

childhood, 787

clinical manifestations of, 847

constitutional factors in, 836

conversion, 838, 848

deficit in, mental age, 975

definition of, 834

delimitation of, 854

dichotomous typologies and, 18

differentiation of, 839, 854

emotional sensitivity and, 841

etiology of, 836

constitutional factors in, 840

developmental factors in, 842

economic factors in, 846

(Volume II pages 619 to 1191}

1236

SUBJECT INDEX

Psycheneurosis Continued

etiology of Continued

organic factors in, 847

situational factors, 845

faulty emergency reactions, 852

incidence of, 833

inheritance of, 519

malingering and, 857

mental age in, 975

obsessive-compulsive, 850

Oedipus conflict and, 837

prognosis in, statistics of, 1154

psychasthenia, 851

psychosis and, 856

re-enactment of infantile conflict in, 837

repetition compulsion and, 838

somatic disease and, 855

symptom patterns of, 838

therapy for, 857

Psychopath, constitutional, 810

Psychopathology,

Janet's conception of, 1135

psychoanalytic, 264, 1137

Psychosis,

affective, 873

depressed forms of, 878

description, 875

history, 873

manic forms of, 875

constitutional type and, 533

crime and, 805

deficit in,

factor analysis of, 988

mental age, 973

nature of, 1020

pattern of, 985

summary on, 1020

task complexity and, 996

efficiency indices, 980

functional, 861 (See also "Involutional

melancholia," "Manic-depressive psy-

chosis," "Paranoia," "Schizophre-

nia")

biochemistry and, 866

brain pathology in, 863, 1124

classification of, 870

constitution in, 863

diagnosis, 871

EEG in, 1081

endocrine function in, 866

etiology of, 862

focal infections in, 865

incidence of, 872

inheritance of, 863

prognosis of, 869

psychogenesis and, 867

psychosurgery in, 864

intelligence selection in, 978

Kent-Rosanoff test in, 1000

language and thought in, 1008

memory and, test of, 1006

mental age in the, 974

table of, 973

organic (See also "Alzheimer's disease,"

"Cerebral arteriosclerosis," "Gen-

eral paralytica," "Senile psychosis,"

"Pick's disease")

EEG in, 1084

vitamin deficiency and, 662

paretic, 559

Psychosis Continued^

perceptual defects in, 990

psychoanalysis in, 1141

psychoneurosis and, 856

reaction-time in, 993

receptor thresholds in, 990

reflex latency in, 995

retention and impression in, 1007

selective test failure in, 984

senile, 560

"septic," 865, 1124

startle pattern in, 1001

statistical prognosis and, 1151

tapping rate in, 998

traumatic, 556

vitamin feeding in, 599

Psychosomatic medicine, history of, 270

Psychosomatic relationships, 269

cardiovascular, 280

culture and, 722

endocrine, 290

epilepsy, 292

experimental neurosis and, 407

genital function, 294

genito-urinary function, 292

institutions conducting research In, 271

methods of research in, 271

neurophysiological mechanisms in, 294

respiratory, 286

skin disturbances, 289

specific correlations, 272

visceral changes in hypnosis, 474

Psychosurgery,

operative procedure in, 864

rationale of, 865

Psychotherapy,

abreaction in, 1135

authoritative, 1116

bibliotherapy as, 1132

catharsis in, 1135

children's, 788

authoritative approaches, 1147

explanatory, 1128

hypnotic, 1110

persuasive, 1115

psychoanalytic, 1135

rational, 1114

reasoning, 1113

re-educative, 1127

statistics of, 1150

suggestion in, 1111

Puberty,

endocrine factors in, 608

interest changes at, 682, 694

case illustration, 704

Oedipus reactivation at, 127, 698

resurgence of sexuality at, 127

sexual reinforcement at, 693

case illustration, 705

Pubescence, definition, 763

Public opinion, polls of, 58

Punishment,

cultural variations in, 728

discipline and, 101

learning and, 80

need for,

paranoiac's, 905

unconscious, 809

reward and, 80

Puppets, 773

(Volume I pages 1 to 618)

SUBJECT INDEX

"37

Quotient,

conceptual, 902, 981

intelligence, 173, 771, 781

personality, defined, 173

Race, inculcating consciousness of, 681

Races,

differences among,

ecology and, 739

heredity and, 517

Rat, abnormal behavior pattern, 416

audiogenic convulsions in, 413

experimental behavior disorders of the.

413

factors influencing susceptibility, 419

Ratings,

personality, 140

heredity and, 516

scales, 150

halo effects in, 152

self, 156

semantic factor in, 152

summary on, 157

validity of, 157

Rationalization, aspiration level and, 375

Reaction,

delayed, 386

long circuiting and, 574

leaving field as defense, 443

Reaction-formation, stimulus-response the-

ory of, 439

Reaction-time,

heredity and, 514

psychotic, 993

Realism, aspiration level and, 372

Reality, distinction between fantasy and,

675

Reality principle, 385

Reasoning,

schizophrenic, 314

therapeutic, 1113

Recommendations, 141

check lists vs. free expression in, 142

improvement of, 143

validity of, 142

Redintegration, 55

Reeducation, therapeutic, 1127

Reference scales, 337

Reflex,

carotid sinus, 947

conditioned,

experimental neurosis and, 389

method of, 392

neurology and, 550

thyroidectomy and, 391

patellar,

latency in psychosis, 995

psychosis and, 977

Regression, 264

behavior theory of, 311

deterioration and, 971

experiments on, 311

Freud's description of, 123

frustration and, 314

infantile, mothering and, 633

Regression Continued

instrumental act, 311

interpretations of, 1018

maze-analogue of, 124

new experience and, 673

primitivation in, 314

repression and, 123

schizophrenia and, 314

stimulus-response theory of, 462

Reinforcement,

fixation and amount of, 308

gradient of, 80

reward and punishment as, 80

time of reward and, 80

Relationships,

child-adult, 653

interpersonal,

cultural variations of, 732

interrelations among, 653

Relativity, cultural,

abnormality and, 722

paranoid delusions and, 721

Relaxation,

progressive, 1120

therapeutic, 1118

Repetition compulsion, 838

Repression, 123, 262

anxiety and, 321

associative (after expulsion), 321

experimental induction of, 323

identification with parents and, 125

measure of existing, 321

regression and, 123

unconscious and, 1136

Resistance,

childhood, 672

anxiety in, 762

psychoanalytic, 328

Respiration,

alkalinity and, 592

disturbances,

emotional, 286

experimental neurosis, 407

fetal, 636

newborn, 635

Response interference (See also "Conflict")

anxiety and, 451

approach-avoidance gradients in and, 435

associative, 459

compromises in, 461

dynamogenesis in, 460

spread of, 463

stages of learning and, 459

types of, 456

Responsibility, moral, crime and, 800

Retardation, depression and, 880

Reward,

learning and, 79

punishment and, 80

stimulation reduction as, 79

Rivalry, sibling, 653

play technique and, 772

Role, habit-adjustment, 59

Rorschach test, 227

brain tumor and, 556

dichotomous typologies and, 19

epileptic responses to, 960

extratensive, introversive types and, 19

method of scoring, 229

nature of, 228

(Volume llpages 619 to 1191)

1238

SUBJECT INDEX

Rorschach test Continued

personality structure revealed in, 228

psychotic responses, 233

tests related to, 235

validity, 232

Rosanoff-Kent test, 223, 1000

Samoa,

adolescent adjustment in, 719

family organization in, 719

"Scatter," 983

Schizophrenia (See also "Dementia prae-

cox")

ambivalence in, 890

apathy and interest in, 1003

catatonic type, 894

childhood, 681, 787

continuity between normal and, 891

cooperation and test performance in,

1004

deficit in, task complexity and, 997

delinquency and, 743

deterioration question in, 896, 1004

test results and, 898

EEG in, 1081

efficiency index in, 980

emotion in, experiments on, 1001

etiology of, life history and, 892

hebephrenic type, 894

history of concept of, 887

infantile experience and, 752

inheritance of, 520

insulin treatment of, 1123

interpretations of, 888

life history and, 752

mental age in, 976

paranoid type of, 895

preparatory set in, 994

reaction-time in, 994

reasoning in, 314

receptor thresholds in, 990

regression in, experiments on, 1017

simple type of, 893

subgroups of, 892

symptomatology, 890

thinking in, 891

dreaming and, 896

experiments on, 1014

interpretations of, 1016

regression and, 900

types of, urban ecology and, 751

variability of performance in, 1004

vocabulary vs. mental age in, 981

Schizothyme, 19, 22

School,

children's maladjustments and, 775

elementary, experience in, 677

nursery, differing reactions to, 668

Sciences, biological and social unification

of, 72

Scientific method, psychoanalysis as, 255

Seizures,

altering rate of, 947

audiogenic in rat, 414

conflict and, 426

criteria, 418

discovery of, 414

Seizures Continued

audiogenic in rat Continued

electrical activity in, 414

heredity of, 422, 508

incidence, 419

overt reaction, 417

precipitating stimulus, 420

susceptibility influences, 420

theoretical implications, 427

epileptic, EEG in, 1069

mechanisms of, 941

migraine, 950

states of, personality and, 952, 956

Self,

childhood evaluation of, 667

childhood experience of, 666

experiences of, constitution and, 666

use of, 1121

Self-confidence, statistical factor of, 39

Self -regulation, 71

Senescence, anoxia effects and, 588

Senile psychosis, 560

mental age in, 976

Services, military, unfit personalities in, 822

case illustrations, 828

Set,

index of, 994

mental, EEG in, 1057

preparatory, schizophrenia and, 994

Sex,

adolescent information of, 694

childhood behavior differences in, 674

endocrine factors in, 608

female cycle of, hormone regulation of,

608

interest in, childhood, 679, 695

perversions of, infantile pleasure striv-

ings and, 622

premarital experience of, cultural varia-

tions in, 695

socialization and, 112

Sexuality,

anxiety and, 117

infantile, 116, 623

criticisms of, 768

inhibition of and aggression, 116

inhibition of and marriage, 119

latency period and, 126

libido and, 117

puberty and, 127

taboo of, 125

thumb-sucking as, 116

Sheep, experimental neurosis in. 408

Shock,

EEG and, 1086

electro-, 1124

metrazol, 1123

Skills, inheritance of, 513

Skin, emotional disturbances of, 289

Sleep,

EEG in, 1068

hypnosis and, 478

Sleeping sickness, 561

Social stimulus value, personality and, 74,

140

Socialization,

aggression in, 112

analogue of in animal experiment, 99

cultural variations in, 724

early infantile, 85

(Volume I pages 1 to fi!8)

SUBJECT INDEX

"39

Socialization Continued

English vs. American, 724

family and, 107

habit progression and, 102

imitation in, 108

learning and, 85

learning in, 106

maturation and, 657

maze-analogue of, 99

reward and, 106

personalization of, 106

sexuality and, 112

special aspects of, 103

Society, preliterate, behavior disorder in,

739

Sociometry, 158

Sociopathy, 931

Somatopsychic, 550

Somatotonia, 544

Somatotype, 539

permanence of, 540

Specificity of behavior, personality traits

and, 51

Spectrum, EEC, 1052

Speech,

children's disorders of, 784

paretic, 559

psychotic, grammatical structure of, 999

schizophrenic, 891

Spirits, evil, disease and, 1107

Standards, group, aspiration level and,

340

Stanford-Binet tests, 973, 977, 983, 984

Startle, pattern of, 1001

Starvation, learning ability after, 596

Statistics, therapeutic, 1150

Status,

childhood changes of, 668

group, 158

personal preference method and, 159

social, 158

behavior and, 57

Stem, brain, motor symptoms and, 551

Stimulation, sensory, EEG and, 1054

Stockbridge, therapeutic community at,

1127

Stomach, neuroses of, 275

Stress,

definition, 380

situations classified, 382

types of, 381

Striving, infantile pleasure, 623

Stroke, 553

Structure,

family, cultural variations in, 726

personality (See "Personality, structure

of")

social, 718

Study, personality, therapeutic value, 1133

Stupor, depressive, 882

catatpnia and, 882

Stuttering,

incidence of, 783

split lateral ity and, 783

Suasion, moral, 1113

persuasion and, 1116

Subconscious, 1109

Sublimation, 320

adolescent, 699

interferences with, 623

Substitution,

alternative tasks and, 319

frustration and, 319

Success, aspiration level and, 343, 373

Sucking,

child-mother attachment and, 631

infantile, initiation of, 628

infantile pleasure in, 624

initiating, 638

need for, 645

restricted and unrestricted,

effects observed, 639

thumbsucking and, 639

Suggestibility, tests of, 183

Suggestion,

direct and indirect, 497

hypnotizing and, 497

persuasion and, 1116

Suicide,

adolescence and, 699

rates of, rural-urban, 740

Super-ego, 110

acquisition of, 697

authority experiences and, 653

conscience and, 110

cultural variations in, 727

Superstition, tests of, 198

Surgery, brain, psychiatric use of, 1124

Swallowing, infantile pleasure in, 624

Symbolic process,

capacity to delay gratification and, 386

frustration tolerance and, 386

Sympathy, varying forms of, 669

Symptoms, physiological, anxiety and, 584

Syncope, 947

Syndromes,

clinical, classification, 552

effort, 584

Korsakow's, 563

Parkinson's, 561

Syphilis, congenital, intellectual retarda-

tion in, 594

System, nervous, functional levels in, 574

Taboo, infantile sex, consequences of, 119

Tanala, family pattern among the, 107

Tantrums, 644

Tapping, speed of and heredity, 514

Tasks, uncompleted, schizophrenic per-

formance on, 1003

Tay-Sachs disease, 777

Tchambuli, family relationship among the,

107

Teaching ability, 154

for casting, 154

student ratings of, 155

Temperament,

basic components of, 541

character and, 8

components, method of finding, 541

cycloid, 21

definitions of, 8

emotion and, 9

endocrine factors in, 606

hypogonadal, 608

inheritance of, 516, 518

inventories of, 186

(Volume 77 pages 619 to

1240

SUBJECT INDEX

Temperament Con tinned

personality and, 8

physique and, 23, 544

history of, 526

scale of, 543

schizoid, 21

tests of, 180

performance type of, 181

self-description, 185

will-temperament, 180

types of, 14

classical theory, 15

dichotomous, 16

psychiatry and, 16

Hippocrates', 8

Kretschmer's, 23

Temperature,

EEC and high, 1064

Temporal lobe, 571

Tension,

definition, 380

psychological, 1109

Testament, New, disease conceptions in,

1108

Tests,

abstract ability, 1012

absurdity and arithmetic progression,

1020

adjustment, 180

art aptitude, 198

association, 181

Kent-Rosanoff, 1000

word, 223

attitude, 190

Babcock test of deterioration, 979

age and, 980, 981

batteries of, 200

character, 174

cross-out, Pressey, 181

honesty, 175

intelligence,

deficit (deterioration) and, 973

qualitative results from in psychosis,

983

scatter in, 983

selective failure on, 984

Stanford-Binet test of abilities in, 984

Wechsler-Bellevue, 978, 984

age and, 978

interests, 192

vocational, 195

inventories of personality, 186

maze, 183

moral knowledge, 174

music ability, 198

opinion, 190

performance, 180

perse veration, 182

persistence, 178, 182

personality, 170

application of, 201

evaluation of, 201

intelligence vs. personality, 172

projective tests of, 214

test variables listed, 199

thematic apperception, 235

Rorschach, 227

self-description, 185

social adequacy, 199

sorting, 1010

Tests Continued

Stanford-Binet, 973, 977, 983, 984

suggestibility, 183

superstition, 198

temperament, 179, 180

Vigotski, 902, 1012, 1015

visual-perception, vocabulary and, 981

values, 195

work analysis, 184

Tetany, alkalinity and, 591

Thematic apperception test, 235

content of, 236

scoring of, 237

validity of, 238

Theories, nature of, 714

Theory,

dynamic, 69

uses of, 63

Therapy,

artistic expression in, 245

authority in, 1116

autosuggestion in, 1112

causes removed in, 858

child, 788

direct psychological, 1110

dynamic growth, 1144

education and, 85

emancipation in, 858

emotional participation in, 858

epileptic, 948

exorcism as, 1108

explanatory, 1128

grasp of relationships in, 858

hypnoanalysis as, 490

hypnotic, 490, 1110

insulin, 1123

learning, associative and, 63

migraine, 950

moral suasion as, 1113

personality study as, 1133

persuasive, 1115

play technique in, 239

prevention and, 1164

psychiatric, HOT

history of, 1107

medication in, 1122

methods of, 1111

outline of, 1156

physical methods of, 1118

statistics of, 1150

surgery in, 1124

vitamin feeding in, 599

psychoanalytic, 256, 1135

rational, 858

relationship, 1148

relaxation, 1119

rest, 1118

shock, EEG and, 1086

suggestion, 1111

symptomatic, 859, 1110

will, 1116

Thinking,

abstract attitude in, 386

cerebral injuries and, 386, 1008

complex (Vigotsky), 902

deficits in, 1008

frustration effects on, 386

language and, deficits in, 1008

obsessive, 851

paralogical, 901

(Volume I pages 1 to 618)

SUBJECT INDEX

1241

Thinking Continued

primitive, 901

schizophrenic, 891

dreaming and, 896

experiments on, 1014

fatigue and, 896

interpretations of, 1016

regression and, 900

symbolic process in, 386

Thresholds,

individual patterns of, 664

receptor, psychosis and, 990

Thumbsucking, 784

sexuality in, 116

Thyroid,

deficiency of,

cretinism and, 603

endemic 1 goiter and, 604

inheritance of, 519

metabolism and, 604

intelligence and feeding, 605

removal and behavior, 391

Tics, 781

Timing, effects of brain lesions and,

561

Toilet, training for,

advice concerning, 641, 646

culture and, 655

Tolerance, frustration, 385

Tone deafness, inheritance of, 515

Totem, 718

paternal ambivalence and, 725

social structure and, 718

Training, negative transfer of, 459

Traits,

abnormal, inheritance of, 514

acquisition of, emotion in, 60

associative learning and, 62

attribution of, 325

general, denied, 61

generality of behavior and, 41

graded series, heredity of, 509

habits as, 54

measurement of, interview method of,

144

principle of association and, 50

repetitipusness of behavior as, 54

specificity of behavior and, 40

statistical conception of, 26

theory of, 40

Transference, psychoanalytic, 1140

Trauma,

birth, 87

brain, symptoms of, 556

head, EEC in, 1078

Treatment (See also "Therapy," Psycho-

therapy")

insulin, 1123

rational, 858

rest, 1118

symptomatic, 859

Trieb,

drive and, 72

impulse and, 72

instinct and, 72

Tripartite psychology, personality and, 10

Tuberculosis, intelligence and, 594

Tumor, brain,

EEC and, 1068

Rorschach and, 556

Twins,

difference between, heredity and environ-

ment in, 510

fraternal, heredity and, 511

identical, 510

intelligence differences of, 512

prenatal non-genetic influences, 512

monovular, identification of, 510

Types,

Appollonian vs. Dionysian, 720

constitutional, history of, 526

digestive, 527

Jaensch's, 20

Jung's, 17

morphological, Kretschmer's, 21, 841

muscular, 527

reaction, concept of, 1126

respiratory-cerebral, 527

Rostan's, 527

temperament, heredity and, 518

theories of, 11

value (Spranger), 196

Voila's, 528

Typologies,

dichotomous, 16

Kiilpe's tachistocopic experiments and,

19

morphology and, 18

normal personality and, 18

personality traits and, 18

psychiatry and, 16

Rorschach test and, 19

table of, 18

interrelations among, 17

somatotyping and the, 539

tripartite, 10, 527, 530

U

Ulcer, peptic, 276

EEC in cases of, 1051

incidence at different times, 722

Unconscious, hypothesis of, 1136

Urinary function, emotion and, 293

Uterus, hysteria and wanderings of, 1108

Vacillation in conflict, 437

stimulation produced in, 438

Valences (See also "Gradients, behavioral")

aspiration level, 356

conflict and, 440

level of aspiration and, 373

Variability, cooperation and schizophrenic.

1004

Variables, psychological, EEC and, 1054

Variance, analysis of heredity and, 507

Verbal summator, 239

Vice, organized, areas of, 746

Vigotsky test, 902, 1012, 1015

Visceratonia, 542

Vision, deficiency of, inheritance of, 515

Vitamins,

A and night blindness, 515

audiogenetic seizure and, 598

behavior and, 597

(Volume II pages 619 to 1191)

1242

SUBJECT INDEX

Vitamins Continued

deficiency of, learning and, 598

feeding effects of, 599

Vocabulary,

deterioration and, 979

original capacity and, 979

test, 902

Vomiting, nervous, 275

W

War, First World, neuropsychiatric illness

in, 1150

Water balance, endocrine regulation of, 601

Waves,

Alpha. 1038

beta, 1039

brain, 1033

epileptic, 944

types of, 1038

delta, 1041

gamma, 1040

Weaning, effects of, 640

Wechsler-Bellevue test, 984

age and, 978

Wehrpsychologie, 149

Well-being, alkalinity and, 592

Will, 1116

education of, 1117

statistical factor, "w," 39, 988

Withdrawal, variability and schizophrenic,

995

Word association tests, 223

clinical value of, 227

complex indicators in, 225

emotional disturbance in, 225

Kent-Rosanoff, 226, 1000

nature of, 224

psychotic responses in, 226, 1000

Word blindness, congenital, 514

Work, social, 1183

World, view of, 730

Writing,

character, 12

children's difficulties in, 784

Youth (See "Adolescence")

Zuni pueblos, Plains Indians and the. 716,

721

(Volume I pages 1 to 618)